Ohio Department of Transportation s3

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: ______

Agent: ______

Phone: ______

Name of Business Bank: ______

2 Banker: ______

Phone: ______

Name of Accounting Firm: ______

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