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Step 1 of 9 - General Firm/Company Structure

11%

Name

This field is for validation purposes and should be left unchanged.

Contact Person

Name(Required)

First Last

Company Name(Required)

Title

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the legal structure of your firm/company(Required)

Sole proprietorship

Partnership

Corporation

Other

Date Established(Required)

Month

Day

Year

Years in business(Required)

Are you a contractor or a consultant?(Required)

Consultant

Contractor

Number of employees

Full-time

Part-time

Identify and indicate the ownership percentage of all shareholders

Are you the sole owner of your company?(Required)

Yes

No

How many Owners does your company have?

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Name(Required)

First Last

Ownership(Required)

Sum of ownership % totals should equal 100%

Describe any recent changes in firm ownership, structure, management, key personnel, etc.

Insurance information

Name of Insurance Co.(Required)

Agent Name(Required)

Phone(Required)

$ Amount(Required)

Type of Coverage(Required)

Is your firm Business Partner Registered (BPR) On PennDOT ECMS System ?

Yes

No

Select your firm's current PennDOT ECMS status below.

Active Pre - Qualified status as an ECMS Contractor

Active Pre-Qualified Exempt status as a Service Provider

Active Annual Consultant Qualifications Package (CQP)

Is your company a small, minority, or disadvantaged business enterprise certified through the PA UCP approval process?(Required)

Yes

No

If yes, please select all demographic categories that apply:(Required)

African American

Asian / Pacific Islander

Hispanic

Native American

Subcontinent Asian

Women-owned

Caucasian

If no, please provide status on progress.(Required)

Bonding information

Name of Bonding Co.(Required)

Agent Name(Required)

Phone

Single

Aggregate

Certifications and References

DBE certification information

Date Certified(Required)

Month

Day

Year

Most Recent Approval (if applicable)(Required)

Month

Day

Year

Certifying Agency(Required)

Prequalification Areas (NAICS)(Required)

Annual gross receipts for the past five (5) years

Year 1 (2017)(Required)

Year 2 (2018)(Required)

Year 3 (2019)(Required)

Year 4 (2020)(Required)

Year 5 (2021)(Required)

Has your firm/company participated in any additional PennDOT offerings (ex. programs, courses, training, networking events, etc.) (Required)

Yes (please describe)

No

Description

Business references

Company

Contact Name

Phone

Business association to which your firm belongs

Association

Membership Type

Needs/Capacity Assessment

Please describe the short-term goals of your firm/company(Required)

Please describe the long-term goals of your firm/company(Required)

Please identify the categories in which you need assistance: (Required)

Business Plan

Marketing Plan

Strategic Action Plan

Operations Assessment

Market Research

Organizational Development

Blueprint Reading

Personnel Management

Scheduling & Purchasing Equipment & Materials Obtaining Permits/Subcontracts

Project Planning & Scheduling Cost Accounting

Bonding & Insurance

Banking Services

Job Cost & Work in Progress Payroll Administration (Federal, State, Fringe, Benefits)

Post Award & Bid Assessment Prompt Payment Procedures Preparing Job Orders & Changes

Marketing Materials Information Systems Consulting Website Development

Networking

Records & Contract Management Developing Overhead/Safe Harbor Rate

Other

(Add additional comments)

Please select the desired work classification from the list below. Please choose all that apply

A - Clearing and Grubbing

B - Building Demolition

C - New Roadway Excavating and Grading

C1 - Other Excavation and Grading (Roadway Patches, Drainage, Structure Related, etc.)

C2 - Drilling and Blasting

C5 - Anchors

C6 - Drilling

C4 - Rubblizing

D - Rigid Base Course

E - Flexible Base Course

F - Bituminous Pavement

F1 - Bituminous Pavement Patching and Repair

F2 - Bituminous Joint and Crack Sealing Yes

F3 - Milling, Rumble Strips, Scarification Bituminous or Concrete

F4 - Bituminous Surface Treatments, Seal Coats

G - Rigid Pavement

G1 - Rigid Pavement Patching and Repair

G2 - Diamond, Carbide Grinding Concrete or Bituminous

G3 - Spall Repair

G4 - Joint Rehabilitation, Sawing and Sealing Concrete or Bituminous

W - Railroad Construction

B1 - Asbestos Removal

C3 - Geotextiles

H - Drainage, Water Main, Storm Sewer

H1 - Pipe and Culvert Cleaning

H2 - Pavement Base Drains

J - Guide Rail, Steel Median Barrier, Fences

J1 - Concrete Median Barrier

J2 - Fencing, Railings

J3 - Impact Attenuating Devices

K - Curbs, Sidewalks, Inlets, Manholes

K1 - Masonry Work

K2 - Concrete and Masonry Coating

L - Slabjacking, Subsealing

M - Landscaping

M1 - Selective Tree Removal, Trimming

M2 - Silt Barrier Fence, Gabions, Erosion Control

M3 - Seeding and Soil Supplements

N - Building Construction and Related Trades

N1 - Related Building Trades

O - Pavement Markings

O1 - Raised, Recessed Pavement Markers

O2 - Plastic Applications

O3 - Paint Applications

P - Highway/Sign Lighting, Traffic Signal Control

P1 - CCTV, RWIS, Automated Anti Deicing Systems

P2 - Highway Advisory Radio Systems (HAR)

P3 - Dynamic Message Signs (DMS)

P4 - Integrated Communication Systems

P5 - Level 1 System Integrators (Hardware)

P6 - Level 2 System Integrators (Software)

P7 - Level 3 System Integrators (Hardware/Software)

P8 - Highway/Sign Lighting, Electrical

Q - Maintenance and Protection of Traffic

R - Sign Placement [Post/Structure Mounted]

R1 - Sign Structures (Refer to Pub. 408, Section 948)

S - Cement Concrete Bridges Over 120 ft.

S0 - Marine Repair

S1 - Cement Concrete Bridges up to 120 ft. and Steel Bridges with Straight Girders up to 120 ft.

S2 - Repair and Rehabilitation of Structures Concrete or Steel

S3 - Modified Concrete Deck Overlays

S4 - Bridge Culverts, Pedestrian Bridges, Timber Bridges

S5 - Structural Walls

S6 - Erection of Prestressed Concrete Beams

S7 - Rebar Installation

S8 - Transportation Tunnels

S9 - Bridge Deck Placement or Repair

T - All Steel Bridges with Curved Girders or Over 120 ft.

T1 - Bridge Removal

T3 - Erection of Fabricated Steel Members

T4 - Welding

T5 - Bearing Pads and Seals

T6 - Expansion Dams

T7 - Bridge Drainage

T8 - Shear Studs, Metal Bridge Deck Forms

T9 - Parapets

U - Pile Driving

U1 - Caissons ( Refer to Pub. 408, Section 1006.3(k) )

V - Field Steel Surface Preparation and Painting

V1 - Shop Steel Painting

V2 - Disposal of Bridge Waste/Containment/Worker Health and Safety

X - Project Preparation and Miscellaneous

Z - Maintenance Type Services

ZZ - Specialty Item Prequal Exempt

Please explain why you would like to participate in this program?(Required)

List (geographic) areas in which your firm/company has presence/does work

City/County/State/Region/District(Required)

Office/Project(Required)

List all major owned/leased equipment

Equipment Description(Required)

Are you willing to enter into a written agreement/developmental plan/confidentiality agreement as part of this program? (Required)

Yes

No

Work Experience

Describe your contracting experience

% Private (Required)

Please enter a number from 0 to 100.

Sum of work experience % totals should equal 100%"

% Government(Required)

Please enter a number from 0 to 100.

Sum of work experience % totals should equal 100%"

List significant projects that began (in progress) or completed in the last 5 years

Project

Type

Customer Name & Contact

Contract Amount

Date Completed

Completed on Time

Any Resulting Claims

List all PennDOT projects completed in the past five (5) years: 

Project

Type

Customer Name & Contact

Contract Amount

Date Completed

Completed on Time

Any Resulting Claims

List all PennDOT projects began (in progress) in the last five (5) years: 

Project

Type

Customer Name & Contact

Contract Amount

Date Completed

Completed on Time

Any Resulting Claims

Additional recent work experience to be considered (this may include work that key individuals currently in your firm/company completed while at another firm/company):

Project

Type

Customer Name & Contact

Contract Amount

Date Completed

Completed on Time

Any Resulting Claims

Has your firm/company ever bid on PennDOT projects?(Required)

Yes

No

Has your firm/company ever participated in PennDOT projects?(Required)

Yes

No

Has your firm been involved in a Mentor/Protégé relationship in the past?(Required)

Yes

No

Please explain why additional mentoring is needed.

What is your annual revenue?(Required)

a. $0-100,000

b. $100,001 - 500,000

c. $500,001 - 2,000,000

d. $2,000,001 - 5,000,000

e. Greater than $5,000,000

How long have you been in business? If you have been in business for less than a year but have over 2 years of experience in professional consulting and engineering or previously running a business, please explain.(Required)

Years of Experience

0-1 Years

1-3 Years

3-10 years

10 years or more

Please Explain

Do you have an established track record as professional services consultant or contractor?(Required)

Yes

No

Are you an independent business entity from the Mentor?(Required)

Yes

No

Are you currently debarred or suspended from doing work by any governmental entity in any state?(Required)

Yes

No

Are you involved in any litigation as a result of professional liability with the Commonwealth of Pennsylvania?(Required)

Yes

No

Yes, but this litigation is not of a material level to affect the ability to perform work

Do you currently have a firm you would like to match with as a Mentor?(Required)

Yes

No

If yes, which firm(Required)

Are you registered with ProRank Academy, the online platform where virtual supportive services are delivered?(Required)

Yes

No

Do you currently utilize assistance from the DB or DBE Supportive Services Programs?(Required)

Yes

No

Have you taken an Annual Needs Assessment with the DB or DBE Supportive Services Center?(Required)

Yes

No

Are you able to commit to the reporting and participation requirements of this program for the term of a contract?(Required)

Yes

No

Please identify the work classifications in which your firm/company has experience:

Earthwork, specifically the following:

Clearing & Grubbing

Building Demolition

New Roadway Excavating & Grading

Other Excavation & Grading

Drilling & Blasting

Anchors

Drilling

Base Course, specifically the following:

Rubblizing

Rigid Base Course

Flexible Base Course

Pavement, specifically the following:

Bituminous Pavement

Bituminous Pavement Patching & Repair

Bituminous Joint & Crack Sealing

Milling, Rumble Strips, Scarification Bituminous or Concrete

Bituminous Surface Treatments, Seal Coats

Rigid Pavement

Rigid Pavement Patching & Repair

Diamond, Carbide Grinding Concrete or Bituminous

Spall Repair

Joint Rehabilitation, Sawing & Sealing Concrete or Bituminous

Railroad Construction

Incidental Construction, specifically the following:

Asbestos Removal

Geotextiles

Drainage, Water Main, Storm Sewer

Pipe & Culvert Cleaning

Pavement Base Drains

Guide Rail, Steel Median Barrier, Fences

Concrete Median Barrier Fencing, Railings

Impact Attenuating Devices

Curbs, Sidewalks, Inlets, Manholes Masonry Work

Concrete and Masonry Coatings

Slabjacking, Subsealing

Roadside, specifically the following:

Landscaping

Selective Tree Removal, Trimming

Silt Barrier Fence, Gabions, Erosion Control

Seeding & Soil Supplements

Building Construction & Related Trades

Related Building Trades

Traffic & Accommodations, specifically the following:

Pavement Markings

Raised, Recessed Pavement Markers Plastic Applications

Paint Applications Highway/Sign Lighting, Traffic Signal Control

CCTV, RWIS, Automated Anti Deicing Systems

Highway Advisory Radio System (HAR)

Dynamic Message Signs (DMS) Integrated Communications Systems

Level 1 System Integrators (Hardware)

Level 2 System Integrators (Hardware

Level 3 System Integrators (Hardware/Software)

Highway/Sign Lighting, Electrical Maintenance & Protection of Traffic Sign Placement (Post/Structure Mounted)

Sign Structures (Refer to Pub. 408, Section 948)

Structures (Bridges):

Cement Concrete Bridges Over 120 ft.

Cement Concrete Bridges up to 120 ft. and Steel Bridges with Straight Girders up to 120 ft.

Repaid & Rehabilitation of Structures Concrete or Steel

Modified Concrete Deck Overlays

Bridge Culverts, Pedestrian Bridges, Timber Bridges

Structural Walls

Erection of Prestressed Concrete Beams

Rebar Installation

Transportation Tunnels

Bridge Deck Placement or Repair

Marine Work

All Steel Bridges with Curved Girders or over 120 ft

Do you provide similar services to those procured by PennDOT on transportation projects (i.e., Structural Design, Traffic Engineering, environmental consulting, etc.)? Please select all that apply

Bridge Inspection

Geotechnical Investigation

GeoPhysical Investigation

Construction

Inspection

Photogrammetric

Geographic Info

Systems

Construction Support Services Right of Way

Acquisition

Cultural Resource

Roadway Design

Design Support Services

Structure Design

Environmental Mitigation Plans

Traffic Engineering

Environment Studies

Underwater Inspection

Field Surveying

Utility Location/Designation

Other

What types of services do you want to add to your experience through participation in the Mentor/Protégé program? Please select all that apply(Required)

Bridge Inspection

Geotechnical Investigation

GeoPhysical Investigation

Construction

Inspection

Photogrammetric

Geographic Info

Systems

Construction Support Services Right of Way

Acquisition

Cultural Resource

Roadway Design

Design Support Services

Structure Design

Environmental Mitigation Plans

Traffic Engineering

Environment Studies

Underwater Inspection

Field Surveying

Utility Location/Designation

Other

Protégé Contractual Requirements Questions

Please acknowledge your willingness to comply with program requirements as noted below.

Work with the ProRank DBE Support Services to complete a Needs Assessment and Technical Assistance Plan.(Required)

Acknowledged

Enter into one Mentor relationship per contract.(Required)

Acknowledged

Protégés must specify the lead individual responsible for implementing the relationship.(Required)

Acknowledged

Establish a Memorandum of Understanding with Mentor.(Required)

Acknowledged

Conduct necessary due diligence in assessing a potential Mentor prior to entering into an agreement.(Required)

Acknowledged

Provide a monthly progress report summarizing the number of hours worked for knowledge/transfer times and services provided.(Required)

Acknowledged

The Protégé, together with the Mentor, will develop a Protégé Learning Plan that will be accomplished over the term of the relationship and will include metrics, regular meetings and milestones.(Required)

Acknowledged

Honor the nondisclosure of any privileged or proprietary information.(Required)

Acknowledged

Please confirm fields before clicking the submit button

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