Fill in a Valid Massachusetts Dsb Application Form

1. Project Name/Location for Which Firm is Filing:

2a. DSB #

Item #

Commonwealth of

Massachusetts

DSB Application Form

2b. Mass. State Project #

(Updated July 2016)

3a.

Firm (Or Joint-Venture) - Name and Address Of Primary Office To Perform The Work:

3e. 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):

3h. Check Below If Your Firm Is Either:



(1) SDO Certified Minority Business Enterprise (MBE)

Email Address:

(2) SDO Certified Woman Business Enterprise (WBE)



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



Telephone No:

Fax No.:

(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 Engrs.

(

)

Planners: Urban./Reg.

(

)

(

)

Civil Engrs.

(

)

Fire Protection Engrs.

(

)

Specification Writers

(

)

(

)

Code Specialists

(

)

Geotech. Engrs.

(

)

Structural Engrs.

(

)

(

)

Construction

(

)

Industrial Hygienists

(

)

Surveyors

(

)

(

)

Cost Estimators

(

)

Interior Designers

(

)

(

)

(

)

Drafters

(

)

Landscape Architects

(

)

(

)

Total

(

)

5.

Has this Joint-Venture previously worked together?

 Yes

 No

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



SDOVBE



SDOVBE



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 Qualification Relevant To The Proposed Project: (Identify Firm By

h.

Other Experience and Qualification Relevant To The Proposed Project: (Identify Firm By

Which Employed, If Not Current Firm):

Which Employed , If Not Current Firm):

a.

Project Name and Location

b. Brief Description Of Project and

c. Client’s Name, Address and Phone

d. Completion

e. Project Cost (In Thousands)

Principal-In-Charge

Services (Include Reference To Areas

Number. Include Name Of Contact Person

Date (Actual

Construction

Fee For Work For

Of Experience Listed In DSB

Or Estimated)

Costs(Actual, Or

Which Firm Was

Advertisement)

Estimated If Not

Responsible.

Completed)

(1)

a.

Project Name and Location

b. Brief Description Of Project and

c. Client’s Name, Address and Phone Number

d. Completion

e. Project Cost (In Thousands)

Principal-In-Charge

Services (Include Reference To

(Include Name Of Contact Person)

Date (Actual

Construction

Fee for Work for

Areas Of Experience Listed In DSB

Or Estimated)

Costs (Actual, Or

Which Firm Was

Advertisement)

Estimated If Not

Responsible

Completed)

(1)

# of Total Projects:

# of Active Projects:

Total Construction Cost (In Thousands)

of Active Projects (excluding studies):

Role

Phases

Construction Costs

Completion Date

Awarding Authority (Include Contact Name and

(In Thousands)

P, C, JV

St., Sch., D.D.,

Project Name, Location and Principal-In-Charge:

(Actual or Estimated)

Phone Number)

(Actual, or

*

C.D.,A.C. *

(R)Renovation or (N)New

Estimated if Not

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Name of Company

Aggregate Amount

Pol icy Number

Expiration Date

Name

Title

MA Reg #

Status/Discipline Name

Title

MA Reg #

Status/Discipline

a.

d.

b.

e.

c.

f.

Name

Title

MA Reg #

Status/Discipline Name

Title

MA Reg #

Status/Discipline

a.

d.

b.

e.

c.

f.

Name and Title

% Ownership

MA Reg.#

Status/Discipline Name and Title

% Ownership

MA Reg.#

Status/Discipline

a.

d.

b.

e.

c.

f.

Submitted By

__________________________________________________

Printed Name and Title _______________________________

Date ____________

(Signature)