Ohio Department of Transportation Disadvantaged Business Enterprises Mentor-Protege Program
Application
Business Information
1. Name of Firm:______Date: ______
2. Name of President (CEO):______
3. Firm’s Address:______(Street, PO Box) (City, State, Zip) (County)
4. Phone Number:______Fax Number: ______
5. E-mail and/or Website: ______
6. Type of Business: ______
7. Business Start Date:______
8. Number of Employees:______
9. Legal Structure of Business
( ) Sole Proprietorship ( ) Corporation: ______( ) Partnership ( ) Other
10. Status of Business Certification Check all that apply.
( ) DBE ( ) EDGE ( ) MBE ( ) HUB
DBE Pre-qualification dollar amount (if applicable): ______
1 11. Annual Gross Receipts ( Last 3 Fiscal Years)
Year Annual Sales ______
______
______
12. Business Professional Support
Name of Insurance Company: ______
Street Address: ______
City/State/Zip Code: ______
Agent: ______
Phone: ______
Name of Bonding Company: ______
Street Address: ______
City/State/Zip Code: ______
Agent: ______
Phone: ______
Name of Business Bank: ______
Street Address: ______
City/State/Zip Code: ______
2 Banker: ______
Phone: ______
Name of Accounting Firm: ______
Street Address: ______
City/State/Zip Code: ______
Certified Public Accountant: ______
Phone: ______
13. Contract Information
Please list the four largest construction/consultant projects you have worked on in the last two years.
Prime Type of Type of Contract Year Project* Contract Amount
______
______
______
______
* Type of Contract: (P) Prime (JV) Joint Venture (SUB) Subcontractor
14. Needs Assessment
Check the categories where you need assistance.
Business Plan Marketing Plan Strategic Action Plan Organizational Development Market Research Operations Assessment Blueprint Reading Personnel Management
3 Scheduling & Purchasing Construction Equipment & Materials Obtaining Permits/Subcontracts Project Planning & Scheduling Cost Accounting Bonding & Insurance Banking Services Job Cost & Work In Progress Payroll Administration Post Award & Bid Assessment Prompt Payment Procedures Preparing Job Orders & Changes Marketing Materials Information Systems Consulting Website Development Records & Contract Management
In the space provided below, state why you want to participate in the ODOT Mentor- Protege Program. Use the back side of this page, if additional space is needed.
4 15. Confidentiality Statement
Mentor-Protege program staff and administrators will not disclose or use for any other purpose business information supplied by the Protege firm other than to establish program eligibility.
16. Waiver and Release
I/we understand and agree that participation in the Mentor-Protege Program is voluntary for both parties. We hereby release, waive and discharge the Mentor from all claims, grievances and all liabilities which may accrue to the Protege as a result of the advice, recommendations, actions or representations made by the Mentor to the Protege.
I/we also understand and agree that ODOT will provide oversight, and administrative support for the program but shall not be held liable for actions taken that are within the program guidelines.
______Signature of Protege Applicant Title Date
. Return Application To
Ohio Department of Transportation Office of Contracts DBE Supportive Services Unit 1980 W. Broad Street 1st Floor Columbus, Ohio 43223
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