<p> Ohio Department of Transportation Disadvantaged Business Enterprises Mentor-Protege Program</p><p>Application</p><p>Business Information</p><p>1. Name of Firm:______Date: ______</p><p>2. Name of President (CEO):______</p><p>3. Firm’s Address:______(Street, PO Box) (City, State, Zip) (County)</p><p>4. Phone Number:______Fax Number: ______</p><p>5. E-mail and/or Website: ______</p><p>6. Type of Business: ______</p><p>7. Business Start Date:______</p><p>8. Number of Employees:______</p><p>9. Legal Structure of Business</p><p>( ) Sole Proprietorship ( ) Corporation: ______( ) Partnership ( ) Other</p><p>10. Status of Business Certification Check all that apply.</p><p>( ) DBE ( ) EDGE ( ) MBE ( ) HUB</p><p>DBE Pre-qualification dollar amount (if applicable): ______</p><p>1 11. Annual Gross Receipts ( Last 3 Fiscal Years)</p><p>Year Annual Sales ______</p><p>______</p><p>______</p><p>12. Business Professional Support</p><p>Name of Insurance Company: ______</p><p>Street Address: ______</p><p>City/State/Zip Code: ______</p><p>Agent: ______</p><p>Phone: ______</p><p>Name of Bonding Company: ______</p><p>Street Address: ______</p><p>City/State/Zip Code: ______</p><p>Agent: ______</p><p>Phone: ______</p><p>Name of Business Bank: ______</p><p>Street Address: ______</p><p>City/State/Zip Code: ______</p><p>2 Banker: ______</p><p>Phone: ______</p><p>Name of Accounting Firm: ______</p><p>Street Address: ______</p><p>City/State/Zip Code: ______</p><p>Certified Public Accountant: ______</p><p>Phone: ______</p><p>13. Contract Information</p><p>Please list the four largest construction/consultant projects you have worked on in the last two years.</p><p>Prime Type of Type of Contract Year Project* Contract Amount</p><p>______</p><p>______</p><p>______</p><p>______</p><p>* Type of Contract: (P) Prime (JV) Joint Venture (SUB) Subcontractor</p><p>14. Needs Assessment</p><p>Check the categories where you need assistance.</p><p> Business Plan  Marketing Plan  Strategic Action Plan  Organizational Development  Market Research  Operations Assessment  Blueprint Reading  Personnel Management</p><p>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</p><p>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.</p><p>4 15. Confidentiality Statement</p><p>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.</p><p>16. Waiver and Release</p><p>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.</p><p>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.</p><p>______Signature of Protege Applicant Title Date</p><p>. Return Application To</p><p>Ohio Department of Transportation Office of Contracts DBE Supportive Services Unit 1980 W. Broad Street 1st Floor Columbus, Ohio 43223</p><p>5</p>