Attachment_A_Application_Approved_clean 260622.docx

OREGON DEPARTMENT OF TRANSPORTATION: RFQ #S-73000-00017259

Right of Way Appraisal Services Application Form

SUBMIT ORIGINAL COMPLETED APPLICATION FORM ALONG WITH 1 ADDITIONAL COPY OF APPLICATION FORM, CURRENT RESUME, AND COPIES OF 3 WORK SAMPLES

Work Sample Exceptions: Copies are not required for listed work samples that were completed for the ODOT Right of Way Section or Region Right of Way Office within the last 3 years. Agency will use the work product submitted for review purposes.

TO:

ODOT Right of Way Section 555 13th Street NE Salem, OR 97301

ATTENTION: Julie Deglow (503) 798-7292 Email : Julie.M.Deglow@ODOT.Oregon.gov

DBA (if different than Appraiser Legal Name):

Street Address:

City:

State:

Zip Code:

Mailing Address (if different than above):

City:

State:

Zip Code:

Email Address:

Phone Number:

Fax Number:

County:

Will you be providing services as an individual/sole proprietor or as an employee of your employer?

|_| Individual/sole proprietor

|_| Employee of employer. List Name of Employer: _ ______________________________ Address:_ ______________________________________________________________ City:_ ____________________________ State:_ __________ Zip Code: ___________ Employer Primary Contact: Phone: Email:

Name of person(s) authorized to sign a Contract:_ _________________________________

Provide business type for you as independent contractor, or for your employer you are working for.

|_| Individual/Sole Proprietor (List name )_ ____________________________________ If you are an employee, provide business type for your employer:

|_| Corporation (List name and Oregon Registration Number)_ ____________________

|_| Limited Liability Company (List name and Oregon Registration #__ _____________

|_| Partnership (List Name and Oregon Registration #) __________________________

Taxpayer Identification Number will be required on a current W-9 Form at the time and as a condition of Contract execution.

Disadvantaged Business Enterprise (DBE) |_| |_|

Emerging Small Business (ESB) |_| |_|

Minority Owned Business Enterprise (MBE) |_| |_|

Women Owned Business Enterprise (WBE) |_| |_|

Please check the box for the ODOT Regions/geographical areas of the State you are willing to work in, or check the “All Regions” box if you are willing to accept work in any and all Regions of the State:

|_| Region 1 (Portland Metro) |_| Region 4 (Central Oregon)

|_| Region 2 (Willamette Valley/North Coast |_| Region 5 (Eastern Oregon)

|_| Region 3 (Southern Oregon) |_| All Regions of State

OREGON DEPARTMENT OF TRANSPORTATION: RFQ # S-73000-00017259

PART 2. Minimum Qualifications This portion of application will be used to determine if the Appraiser has the minimum qualifications to be considered for selection to the Qualified Appraisers List (“QAL”).

Respondents: Include a copy of your current resume with your application packet submittal.

EDUCATION

Do you have a High School Diploma? Yes |_| No |_| If no, GED Yes |_| No|_|

Do you have a College Degree? Yes |_| No |_| If yes, type: Associate |_| Bachelors |_| Masters |_| If Degree, in what field of Study? _ ______________________________________________________________ If no college degree, how many years of college education do you have? _ _________________

EXPERIENCE: (List experience in real estate field that demonstrates a knowledge of complex real property valuations)

JOB #1

Business Name (If Self Employed just state name):

Period of Employment: From: To: Reason for Leaving (if applicable):

List type of work performed (Be sure to list the type of property valuations conducted):

JOB #2

Business Name (If Self Employed just state name):

Period of Employment: From: To: Reason for Leaving (if applicable):

JOB #3

Business Name (If Self Employed just state name):

Period of Employment: From: To: Reason for Leaving (if applicable):

LICENSES AND PROFESSIONAL DESIGNATIONS

Are you an actively licensed, state certified general real estate appraiser in Oregon: Yes |_| No |_| License #: Expiration Date:

Other Relevant Licenses or Professional Designations

OREGON DEPARTMENT OF TRANSPORTATION: RFQ # S-73000-00017259

PART 3. Appraisal Experience and Work Samples This portion of the application will be evaluated by the Right of Way Section’s Chief Appraiser to determine if the Appraiser/Consultant will be added to the QAL.

APPRAISAL EXPERIENCE AND WORK SAMPLES

What period of time have you actively performed appraisal work? From: To:

What type of appraisals have you conducted and how many would you estimate you have completed within the last five (5) years? ___________________________________________________________________

How many years have you actively worked on completing eminent domain appraisals? _______________

For any eminent domain appraisals, please provide how many you have completed within the last five (5) years.

Have you had to provide court testimony in support of any of your eminent domain appraisals?

Yes |_| No |_| If yes, provide more information on the appraisal and the outcome of the case in which you testified. _ ___

List 3 samples of appraisals you have completed that support the experience you provided above.

PROVIDE A COPY OF EACH WORK SAMPLE WITH YOUR SUBMISSION. (ODOT may contact any of the Owner/Contract Officers for reference of your work).

APPRAISAL #1

Project Name or Appraisal Description: _____________________________________________________ Completion Date:_ _______________

Prime Contractor |_| Subcontractor |_| Contract Amount $

Type of Appraisal

Owner/Contract Officer

Telephone: Email

APPRAISAL #2

Project Name or Appraisal Description: __________________________________________________

Completion Date: ________________

Prime Contractor |_| Subcontractor |_| Contract Amount $

Type of Appraisal

Owner/Contract Officer

Telephone: Email

APPRAISAL #3

Project Name or Appraisal Description: __________________________________________________

Completion Date: ________________

Prime Contractor |_| Subcontractor |_| Contract Amount $

Type of Appraisal

Owner/Contract Officer

Telephone: Email

Application Form Certification Statement

I hereby certify that all information contained within this Right of Way Application Form is true and accurate to the best of my knowledge. I hereby authorize and request any person, agency or firm to furnish any pertinent information requested by Oregon Department of Transportation deemed necessary to verify the statements made in this Application.

Printed name of person signing below _ ________________________________________________________

FOR ODOT OFFICE USE ONLY

Date Application received Received by

Date Application reviewed Reviewed by

Final Evaluation Score _ _____

Application is |_| Rejected |_| Accepted

If Rejected, Basis of Rejection |_| Application Incomplete |_| Minimum Qualifications Not Met |_| Minimum Score Not Met

Approval Date: Approved by:

Level 3 - Restricted

Level 3 - Restricted

RFQ Application Form Page 6 of 6 Revised 06/15/2026Level 3 - Restricted