Attachment A - Standard Designer Application.pdf

Updated July 2016 Municipalities & Other Public Agencies Form Page 1

Commonwealth of Massachusetts

Standard Designer Application Form for Municipalities and Public Agencies not within DSB Jurisdiction (Updated July 2016)

1. Project Name/Location For Which Firm Is Filing: 2. Project #

This space for use by Awarding Authority only.

3a. Firm (Or Joint-Venture) - Name and Address Of Primary Office To Perform The Work: 3. Name Of Proposed Project Manager:

For Study: (if applicable)

For Design: (if applicable)

3b.

Date Present and Predecessor Firms Were Established:

3f. Name and Address Of Other Participating Offices Of The Prime Applicant, If Different From Item 3a Above:

3c.

Federal ID #:

3g. Name and Address Of Parent Company, If Any:

3d. Name and Title Of Principal-In-Charge Of The Project (MA Registration Required):

3. Check Below If Your Firm Is Either:

(1) SDO Certified Minority Business Enterprise (MBE)

Email Address: (2) SDO Certified Woman Business Enterprise (WBE)

Telephone No:

Fax No.:

(3) SDO Certified Minority Woman Business Enterprise (M/WBE)

(4) SDO Certified Service Disabled Veteran Owned Business Enterprise (SDVOBE)

(5) SDO Certified Veteran Owned Business Enterprise (VBE)

4. Personnel From Prime Firm Included In Question #3a Above By Discipline (List Each Person Only Once, By Primary Function -- Average Number Employed Throughout The Preceding 6 Month Period. Indicate Both The Total Number In Each Discipline And, Within Brackets, The Total Number Holding Massachusetts Registrations):

Admin. Personnel ( ) Ecologists ( ) Licensed Site Profs. ( ) Other ( )

Architects ( ) Electrical Engrs. ( ) Mechanical Engrs. ( ) ( ) Acoustical Engrs. ( ) Environmental

( ) Planners: Urban./Reg. ( ) ( ) Civil Engrs. ( ) Fire Protection

( ) Specification Writers ( ) ( )

Code Specialists ( ) Geotech. Engrs. ( ) Structural Engrs. ( ) ( ) Construction Inspectors ( ) Industrial

( ) Surveyors ( ) ( )

Cost Estimators ( ) Interior Designers ( ) ( ) ( ) Drafters ( ) Landscape

( ) ( ) Total

5. Has this Joint-Venture previously worked together? Yes No

Updated July 2016 Municipalities & Other Public Agencies Form Page 2

6. List ONLY Those Prime And Sub-Consultant Personnel Specifically Requested In The Advertisement. This Information Should Be Presented Below In The Form Of An Organizational Chart.

Include Name Of Firm And Name Of The One Person In Charge Of The Discipline, With Mass. Registration Number, As Well As MBE/WBE Status, If Applicable:

CITY / TOWN / AGENCY

Prime Consultant Principal-In-Charge

Discipline (from advertisement)

Name Of Firm

Person In Charge Of Discipline Mass. Registr. #

MBE/WBE Certified (If Applicable)

Mass. Registr. #

MBE/WBE Certified (If Applicable)

Mass. Registr. #

MBE/WBE Certified (If Applicable)

Mass. Registr. #

MBE/WBE Certified (If Applicable)

Project Manager for Study

Project Manager for Design

Updated July 2016 Municipalities & Other Public Agencies Form Page 3

7. Brief Resume of ONLY those Prime Applicant and Sub-Consultant personnel requested in the Advertisement. Include Resumes of Project Managers. Resumes should be consistent with the persons listed on the Organizational Chart in Question # 6. Additional sheets should be provided only as required for the number of Key Personnel requested in the Advertisement and they must be in the format provided. By including a Firm as a Sub-Consultant, the Prime Applicant certifies that the listed Firm has agreed to work on this Project, should the team be selected.

a. Name and Title Within Firm: a. Name and Title Within Firm:

b. Project Assignment: b. Project Assignment:

c. Name and Address Of Office In Which Individual Identified In 7a Resides: c. Name and Address Of Office In Which Individual Identified In 7a Resides:

MBE MBE

WBE

WBE

SDVOBE SDVOBE

VBE VBE

d. Years Experience: With This Firm: With Other Firms: d. Years Experience: With This Firm: With Other Firms:

e. Education: Degree(s) /Year/Specialization e. Education: Degree(s) /Year/Specialization

f. Active Registration: Year First Registered/Discipline/Mass Registration Number f. Active Registration: Year First Registered/Discipline/Mass Registration Number

g. Current Work Assignments and Availability For This Project:

g. Current Work Assignments and Availability For This Project:

h. Other Experience and Qualifications Relevant To The Proposed Project: (Identify Firm By Which Employed, If Not Current Firm):

h. Other Experience and Qualifications Relevant To The Proposed Project: (Identify Firm By Which Employed, If Not Current Firm):

Updated July 2016 Municipalities & Other Public Agencies Form Page 4

8a. Current and Relevant Work By Prime Applicant Or Joint-Venture Members. Include ONLY Work Which Best Illustrates Current Qualifications In The Areas Listed In The Advertisement (List Up To But Not More Than 5 Projects).

a. Project Name And Location Principal-In-Charge

b. Brief Description Of Project And Services (Include Reference To Relevant Experience)

C. Client’s Name, Address And Phone Number (Include Name Of Contact Person)

d. Completion Date (Actual Or Estimated)

e. Project Cost (In Thousands) Construction Costs (Actual, Or Estimated If Not Completed)

Fee for Work for Which Firm Was Responsible

(1)

(2)

(3)

(4)

(5)

Updated July 2016 Municipalities & Other Public Agencies Form Page 5

8b. List Current and Relevant Work By Sub-Consultants Which Best Illustrates Current Qualifications In The Areas Listed In The Advertisement (Up To But Not More Than 5 Projects For Each Sub- Consultant). Use Additional Sheets Only As Required For The Number Of Sub-Consultants Requested In The Advertisement.

Sub-Consultant Name:

a. Project Name and Location

Principal-In-Charge

b. Brief Description Of Project and

Services (Include Reference To Relevant Experience

c. Client’s Name, Address And Phone Number. Include Name Of Contact Person

d. Completion Date (Actual Or Estimated)

e. Project Cost (In Thousands) Construction Costs (Actual, Or Estimated If Not Completed)

Fee For Work For Which Firm Was/Is Responsible

(1)

(2)

(3)

(4)

(5)

Updated July 2016 Municipalities & Other Public Agencies Form Page 6

9. List All Projects Within The Past 5 Years For Which Prime Applicant Has Performed, Or Has Entered Into A Contract To Perform, Any Design Services For All Public Agencies Within The

Commonwealth.

# of Total Projects:

# of Active Projects: Total Construction Cost (In Thousands) of Active Projects (excluding studies):

Role

P, C, JV

Phases St., Sch., D.D., C.D.,A.C.*

Project Name, Location and Principal-In-Charge Awarding Authority (Include Contact Name and Phone Number)

Construction Costs (In Thousands) (Actual, Or Estimated If Not

Completion Date (Actual or Estimated) (R)Renovation or (N)New

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

* P = Principal; C = Consultant; JV = Joint Venture; St. = Study; Sch. = Schematic; D.D. = Design Development; C.D. = Construction Documents; A.C. = Administration of Contract

Updated July 2016 Municipalities & Other Public Agencies Form Page 7

10. Use This Space To Provide Any Additional Information Or Description Of Resources Supporting The Qualifications Of Your Firm And That Of Your Sub-Consultants For The Proposed Project.

If Needed, Up To Three, Double-Sided 8 ½” X 11” Supplementary Sheets Will Be Accepted. APPLICANTS ARE ENCOURAGED TO RESPOND SPECIFICALLY IN THIS SECTION TO THE

AREAS OF EXPERIENCE REQUESTED IN THE ADVERTISEMENT.

Be Specific – No Boiler Plate

11. Professional Liability Insurance:

Name of Company Aggregate Amount Policy Number Expiration Date

12. Have monies been paid by you, or on your behalf, as a result of Professional Liability Claims (in any jurisdiction) occurring within the last 5 years and in excess of $50,000 per incident? Answer YES or NO. If YES, please include the name(s) of the Project(s) and Client(s), and an explanation (attach separate sheet if necessary).

13. Name Of Sole Proprietor Or Names Of All Firm Partners and Officers:

Name Title MA Reg # Status/Discipline Name Title MA Reg # Status/Discipline

a. d.

b. e.

c. f.

14.

If Corporation, Provide Names Of All Members Of The Board Of Directors:

Name Title MA Reg # Status/Discipline Name Title MA Reg # Status/Discipline

a. d.

b. e.

c. f.

15. Names Of All Owners (Stocks Or Other Ownership):

Name And Title % Ownership MA. Reg.# Status/Discipline Name And Title % Ownership MA. Reg.# Status/Discipline

a. d.

b. e.

c. f.

16.

I hereby certify that the undersigned is an Authorized Signatory of Firm and is a Principal or Officer of Firm. I further certify that this firm is a “Designer”, as that term is defined in Chapter 7C, Section 44 of the General Laws, or that the services required are limited to construction management or the preparation of master plans, studies, surveys, soil tests, cost estimates or programs.

The information contained in this application is true, accurate and sworn to by the undersigned under the pains and penalties of perjury.

Submitted by (Signature)

Printed Name and Title

Date