North Carolina Department of Transportation

Transcription

1 North Carolina Department of Transportation Private Consulting Firm Qualifications Package NAME OF FIRM DATE STATE YEAR ESTABLISHED CORPORATE ADDRESS A/C & TEL. NO. Physical Address: Mailing Address: ( ) FAX NO. ( ) NORTH CAROLINA BRANCH OFFICE(S) A/C & TEL. NO. Physical Address: Mailing Address: ( ) CONTACT PERSON Corporate: NC Branch: FAX NO. ( ) A/C & TEL NO. FAX NO. A/C & TEL NO. FAX NO. ( ) ( ) ( ) ( ) address: address: This application is based on the following factors: (Check appropriate designation) CERTIFIED TOTAL EMPLOYEES ORGANIZATION TYPE OF APPLICATION DBE IN NC IN FIRM Individual New Yes Total Employees in Firm Partnership Updated No Total Employees in Corporation Reinstatement (If yes, attach a copy NC Offices of NCDOT certification letter) Total PE s in NC Offices FEDERAL TAX IDENTIFICATION NUMBER Total LG s in NC Offices DATE OF REGISTRATION AND REGISTRATION NUMBER WITH SECRETARY OF STATE S OFFICE DATE NUMBER (if applicable) Total PLS s in NC Offices FIRM REGISTERED WITH NC STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND LAND SURVEYORS Yes License Number No (If yes, attach copy of latest certificate or renewal letter from Board) FIRM REGISTERED WITH NORTH CAROLINA BOARD FOR LICENSING OF GEOLOGISTS Yes License Number No (If yes, attach copy of latest certificate or renewal card from Board) I certify the information contained within this application is accurate. Submission of false information is cause for denial of prequalification with the North Carolina Department of Transportation. NAME OF FIRM OR INDIVIDUAL SUBMITTING APPLICATION NAME AND TITLE OF PERSON SIGNING: Signature Date * This form can also be found at our web site: (Click on Consultant Specific PEF Qualifications - Prequalifications Form) October 1, 1995 (Rev. 2/14/03) -1- PEFQUAL-1

2 Highway Design Branch Geologists Photogrammetrists Hydraulics Engineers Environmental Soils Engineers Engineers Transportation Engineers Bridge Engineers Electrical Engineers Surveyors Geologists Photogrammetrists Hydraulics Engineers Environmental Soils Engineers Engineers Transportation Engineers Bridge Engineers Electrical Engineers Surveyors If new firm, or existing firm adding new area of expertise, send a sample of work for each new area marked. ROADWAY DESIGN Rural Roadway Design Urban Roadway Design Interchange Design (sample should include MicroStation & GEOPAK capabilities) SURVEYING GPS (sample should include equipment list) SUE Route Location Surveys Vangarde PHOTOGRAMMETRY Photogrammetric Services Aerial Photography Services (sample should include equipment list) BRIDGE DESIGN Bridges - Spans under 200 Bridges - Spans over 200 GEOTECHNICAL SERVICES Laboratory Testing Services Drilling Services Engineering Services ENVIRONMENTAL SERVICES Hazardous Waste Site Analysis Preliminary Site Assessment Detailed Site Reconnaissance/Site Sampling Laboratory Services Remediation Services Underground Storage Tank Analysis Site Assessment Tank Removal/Disposal CSA/CAP Laboratory Services Site Remediation Services HYDRAULICS Hydraulic Design - Bridges & Box Culverts Hydraulic Design - Highways Hydrology Storm Water Management Scour UTILITIES Utilities by Others (Plans) Utility Construction (Plans, Specs, & Estimates) Visualization Highway Design Branch continued October 1, 1995 (Rev. 2/14/03) -2- PEFQUAL-1

3 Highway Design Branch - Soils and Foundation Design Geologists Hydraulics Engineers Engineering Technicians Geotechnical Engineers Surveyors Geologists Hydraulics Engineers Engineering Technicians Geotechnical Engineers Surveyors If new firm, or existing firm adding new area of expertise, send 2 samples of work for each new area marked to show your expertise with State DOTs. GEOTECHNICAL ENGINEERING SERVICES DESIGN SERVICES (Submit complete design reports, list of latest design software) TESTING SERVICES (Submit complete testing reports, list of latest equipment and software) Deep and Shallow Foundation Design Retaining Walls Soil Nail Walls (SNW) Tieback Walls Pile Panel Walls MSE Walls Cantilever, Fabric Walls Other Soil Improvements Slope Stability and Embankment Settlements Design & Analysis Pile Driving Analyzer Crosshole Sonic Logging (CSL) Pile Integrity Test (PIT) Statnamic Osterberg Load Cell Static Load Test Drilled Pier Inspection Device (SID) Vibration Monitoring Other Landslides mitigation and Analysis Rock Slope Design and Analysis Tunnel Design (for both) Contact Person: Nancy L. Gay - 919/ Highway Design Branch [email protected] 1584 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -2a- PEFQUAL-1

4 Construction Services Construction Technicians Surveyors Cost Estimators Transportation Claims Analysts Engineers CPM Schedulers Soils Engineers Construction Managers Structural Engineers Construction Technicians Surveyors Cost Estimators Transportation Claims Analysts Engineers CPM Schedulers Soils Engineers Construction Managers Structural Engineers CONSTRUCTION Roadway Construction Engineering & Construction Contract Claim Analysis Inspection Structures Construction Engineering & Inspection Contact Person: Patrick Riddle - 919/ [email protected] Contractual Services Section 1543 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -3- PEFQUAL-1

5 Traffic Engineering & Safety Systems Services Software Engineers GIS Staff Electrical Engineers Structural Engineer Transportation Engineers Software Engineers Electrical Engineers GIS Staff Structural Engineer Transportation Engineers INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: TRAFFIC ENGINEERING Traffic Control & Pavement Marking Signals & Geometrics Sign Design Signal System Design Congestion Management Strategies Traffic Data Collection Intelligent Transportation Systems Signal System Timing Development & Implementation Signal Equipment Design/Application Contact Person: Kenneth W. Ivey, PE - 919/ [email protected] Traffic Engineering Branch 1561 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -4- PEFQUAL-1

6 Project Development & Environmental Analysis Traffic Noise & Air Public Involvement Quality Specialists Specialists Community Planners GIS NEPA/SEPA Practitioners Architectural Historians Environmental Transportation Planners Soil Scientists Engineers Archaeologists Biologists Sociologists Traffic Noise & Air Public Involvement Quality Specialists Specialists Community Planners GIS NEPA/SEPA Practitioners Architectural Historians Environmental Transportation Planners Soil Scientists Engineers Archaeologists Biologists Sociologists PROJECT PLANNING Preparation of NEPA/SEPA Environmental Documents OFFICE OF HUMAN ENVIRONMENT (OHE) Public Involvement Indirect & Cumulative Impacts Assessment Archaeological Resource Surveys Historic Architectural Surveys of Standing Structures (Buildings & Bridges) Traffic Noise Analysis Air Quality Analysis Community Impact Assessment & Environmental Justice Safety and Health OFFICE OF NATURAL ENVIRONMENT (ONE) Threatened & Endangered Species Survey & Studies Ecological & Biotic Community Studies Wetland and Stream Delineation Wetland, Stream, and Buffer Permitting Wetland Mitigation Site Planning Wetland Mitigation Site Design and Construction Oversight Stream Biological Monitoring Stream Mitigation Site Plan Stream Mitigation Site Design and Construction Oversight Freshwater Mussel Surveys Contact Persons: (919) Pam Rogers x 219, Beth Harmon x 312, Carl Goode [email protected] (Project Planning) [email protected] (Natural Environment) [email protected] (Human Environment) Project Development & Environmental Analysis 1548 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -5- PEFQUAL-1

7 Surveyors (PLS) GIS Cartographers Database Programmers Drafting Technicians GIS Analysts GIS Programmers GIS Technicians Cartographers Database Programmers Surveyors (PLS) Drafting Technicians GIS Analysts GIS Programmers GIS Technicians Cartography Linear Referencing System Development Drafting Environmental Data Collection GIS Analysis GIS Application Development (Programming) GIS Data Conversion GIS Data Validation GIS - Transportation Planning Applications GPS Data Collection GPS Application Development (Programming) Internet GIS Application Development Remote Sensing Application Development Remote Sensing Data Collection Remote Sensing Data Processing Spatial Database Applications Spatial Database Development Transportation Data Collection Vehicle Routing Video Logging Linear Referencing System Applications Contact Person: Forrest Robson, PE - 919/ x204 [email protected] Geographic Information Systems 1587 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -6- PEFQUAL-1

8 Bridge Maintenance Bridge Inspectors Bridge Analysts Draftsman/CADD Electrical Engineers Hydraulics Engineers Soils Engineers Bridge Engineers Surveyors Environmental Engineers Geologists Bridge Inspectors Bridge Analysts Draftsman/CADD Electrical Engineers Hydraulics Engineers Soils Engineers Bridge Engineers Surveyors Environmental Engineers Geologists NBIS Municipal Bridge Inspection Route Location Surveys Bridge Design - Spans under 200' Hydraulic Design - Bridges & Box Culverts Hydrology Scour Geotechnical Laboratory Services Geotechnical Drilling Services Geotechnical Engineering Services Erosion and Sediment Control Stormwater Management Hydraulic Design - Open Channels Stream Restoration - Mitigation Wetland Mitigation Contact Person: John Emerson, PE - 919/ x13 [email protected] Bridge Maintenance Unit 1565 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -7- PEFQUAL-1

9 Materials & Tests Biologists Lumber Inspectors Certified Welding Inspectors Chemists Other Metals and Coatings Inspectors OFFICE LOCATIONS LOCATION OF OFFICES THAT WILL PROVIDE SERVICES Laboratory Services Water/Wastewater/Soil/Sludge Inspection Services Inspection of Metal Products Inspection of Wood Products Contact Person: Jack E. Cowsert, PE - 919/ [email protected] Materials & Tests Unit 1564 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -8- PEFQUAL-1

10 Pavement Management Pavement Design Pavement Analysis Pavement Distress Identification Pavement Management Pavement Design Pavement Analysis Pavement Distress Identification Pavement Management Pavement Design Pavement Condition Surveys Pavement Analysis Pavement Management Systems Pavement Deflection Testing & Backcalculation Skid Testing Profilometer & Reporting Ground Penetrating Radar & Analysis Contact Person: Jerry Blackwelder, PE - 919/ [email protected] Pavement Management Unit 1593 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -9- PEFQUAL-1

11 Safety & Loss Control Environmental Engineers Safety Engineers Industrial Hygienist Environmental Engineers Safety Engineers Industrial Hygienist ENVIRONMENTAL SERVICES Hazardous Waste Site Analysis Preliminary Site Assessment Detailed Site Reconnaissance/Site Sampling Laboratory Services Remediation Services Underground Storage Tank Analysis Site Assessment Tank Removal/Disposal CSA/CAP Laboratory Services Site Remediation Services Contact Person: R. K. Andrews, Jr., CSP - 919/ x241 [email protected] Safety & Loss Control 1594 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -10- PEFQUAL-1

12 Statewide Planning Public Involvement Specialists GIS Transportation Engineers Land Use Planners Environmental Specialists Transportation Modelers GIS Transportation Engineers Land Use Planners Environmental Specialists Transportation Modelers Public Involvement Specialists Transportation Planning Traffic Forecasting Model Development Transportation Plan Development Functional Design Public Involvement Environmental Analysis Contact Persons: Mike Bruff, PE - 919/ / Laura Cove, PE - 919/ [email protected] [email protected] Statewide Planning Branch 1554 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -11- PEFQUAL-1

13 Roadside Environmental - CORPORATE HEADQUARTERS Soil & Water Engineering Section Agricultural Engineers Hydraulic Engineers Environmental Engineers Agricultural Engineers Hydraulic Engineers Environmental Engineers Erosion and Sediment Control Hydrology Stormwater Management Hydraulic Design - Open Channels Stream Restoration/Mitigation Wetland Mitigation Contact Person: David B. Harris - 919/ [email protected] Roadside Environmental Unit Soil and Water Engineering Section 1557 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -12- PEFQUAL-1

14 Roadside Environmental - Environmental Operations Section Draftsman/CADD Environmental Engineers Geologists Certified Hazardous Materials Managers Surveyors Draftsman/CADD Environmental Engineers Geologists Certified Hazardous Materials Managers Surveyors ENVIRONMENTAL SERVICES Hazardous Waste Site Analysis Preliminary Site Assessment Detailed Site Reconnaissance/Site Sampling Laboratory Services Remediation Services Underground Storage Tank Analysis Site Assessment Tank Removal/Disposal CSA/CAP Laboratory Services Site Remediation Services Contact Person: T. C. Niver, PG, CHMM [email protected] Roadside Environmental Unit Environmental Operations Section 4809 Beryl Road Raleigh, NC October 1, 1995 (Rev. 2/14/03) -13- PEFQUAL-1

15 Rail Division - CORPORATE HEADQUARTERS Engineering & Safety and Operations Branches Geologists Environmental Hydraulics Engineers Engineers Soils Engineers Architects Traffic Engineers Bridge Engineers Construction Railroad Engineers Surveyors Inspectors Roadway Engineers Photogrammetrists Geologists Environmental Hydraulics Engineers Engineers Soils Engineers Architects Traffic Engineers Bridge Engineers Construction Railroad Engineers Surveyors Inspectors Roadway Engineers Photogrammetrists RAIL-HIGHWAY CROSSING Traffic Separation Studies and Crossing Evaluation Studies Railroad Crossing Signal and Traffic Engineering Services RAIL ENGINEERING Track Design, Survey, and Layout Railroad Signal System Plans Review of Engineering Drawings, Standards and Specifications Rail Construction Project Inspection and Management Boundary and Location Surveys Project Preliminary/Conceptual Plans and Visualizations Rail Corridor Maintenance Assessments, Surveys, and Lease Studies Rail Corridor Traffic Modeling and Capacity/Feasibility Studies OPERATIONS FACILITIES DESIGN AND MANAGEMENT Passenger Station Design Historic Passenger Station Renovations Passenger Platforms Construction Administration Maintenance Facility Rail Facilities Rail Sidings Landscape and Streetscape Design Contact Person: Arthur Petteway, PE - 919/ [email protected] Rail Division (Engineering & Safety Branch) 1556 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -14- PEFQUAL-1

16 Rail Division - Planning Branch Traffic Noise & Air Bridge Engineers Quality Specialists Public Involvement Architect Historians Specialists Transportation Engineers Geologists Transportation Planners Hydraulic Engineers Modelers Archaeologists Soils Engineers Environmental Biologists Railroad Engineers Engineers NEPA/SEPA Practitioners Traffic Noise & Air Bridge Engineers Quality Specialists Public Involvement Architect Historians Specialists Transportation Engineers Geologists Transportation Planners Hydraulic Engineers Modelers Archaeologists Soils Engineers Environmental Biologists Railroad Engineers Engineers NEPA/SEPA Practitioners PROJECT PLANNING ENVIRONMENTAL SERVICES Route Location & Feasibility Studies Preparation of Environmental Documents Rail Functional and Preliminary Design Studies of Economic and Fiscal Impact of Rail Related Activities Demand Modeling, Ridership, Revenue, Operating Costs for Commuter and Intercity Passenger Rail Operations Natural Resources Ecological & Biotic Community Studies Threatened & Endangered Species Investigation Wetland and Stream Delineations Wetland and Stream Mitigation Site Planning Train Performance and Rail Line Capacity Analysis Technical and Negotiation Assistance in Securing Rail Lines or Corridors Cultural Resources Archaeological Resource Surveys Standing Historic Structure Surveys Traffic Noise Analysis Air Quality Analysis Full NEPA/SEPA Documentation Environmental Permits Acquisition Contact Person: Arthur Petteway, PE - 919/ (See page 13 for [email protected] mailing address) October 1, 1995 (Rev. 2/14/03) -15- PEFQUAL-1

17 Program Development Traffic Noise & Air Quality Specialists Public Involvement Specialists Community Planners GIS Environmental Architectural Historians Engineers Transportation Engineers Soil Engineers Transportation Planners Hydraulics Engineers Biologists Archaeologists Traffic Noise & Air Quality Specialists Public Involvement Specialists Community Planners GIS Environmental Architectural Historians Engineers Transportation Engineers Soil Engineers Transportation Planners Hydraulics Engineers Biologists Archaeologists PROJECT PLANNING Route Location, Preliminary Design & Feasibility Studies Preparation of NEPA/SEPA Environmental Documents Traffic Projections Highway & Signal Capacity Analysis Traffic Projections HUMAN ENVIRONMENTAL SERVICES Public Involvement Indirect & Cumulative Impacts Assessment Archaeological Resource Surveys Historic Architectural Surveys of Standing Structures (Buildings & Bridges) Traffic Noise Analysis NATURAL ENVIRONMENTAL SERVICES Threatened & Endangered Species Survey & Studies Ecological & Biotic Community Studies Wetland and Stream Delineation Wetland and Stream Permitting Wetland Mitigation Site Planning and/or Construction Stream Biological Monitoring Stream Mitigation Site Planning & Restoration Freshwater Mussel Surveys Air Quality Analysis Community Impact Assessment & Environmental Justice Contact Persons: Derrick W. Lewis, PE - 919/ x350 [email protected] Program Development Branch 1534 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -16- PEFQUAL-1

18 Equipment & Inventory Control Unit Geologists Electrical Engineers Soils Scientists Surveyors Environmental Engineers NC OFFICE/S Geologists Electrical Engineers Soils Scientists Surveyors Environmental Engineers GEOTECHNICAL SERVICES Laboratory Testing Services Drilling Services Engineering Services ENVIRONMENTAL SERVICES Hazardous Waste Site Analysis Preliminary Site Assessment Detailed Site Reconnaissance/Site Sampling Laboratory Services Remediation Services Underground Storage Tank Analysis Site Assessment Tank Removal/Disposal CSA/CAP Laboratory Services Site Remediation Services Contact Persons: Eric Motzno - 919/ (Delivery) Equipment & Inventory Control Unit 4809 Beryl Road Raleigh, NC (Mail) 1566 Mail Service Center Raleigh, NC [email protected] October 1, 1995 (Rev. 2/14/03) -17- PEFQUAL-1

19 Division Design/Construct Limited Services* Geologists Photogrammetrists Hydraulics Engineers Environmental Soils Engineers Engineers Transportation Engineers Bridge Engineers Electrical Engineers Surveyors Geologists Photogrammetrists Hydraulics Engineers Environmental Soils Engineers Engineers Transportation Engineers Bridge Engineers Electrical Engineers Surveyors INDICATE TYPE OF PROJE CTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: If new firm, or existing firm adding new area of expertise, send a sample of work for each new area marked. ROADWAY DESIGN Rural Roadway Design Urban Roadway Design (sample should include computer design capabilities -MicroStation & GEOPAK preferred) TRAFFIC ENGINEERING Traffic Control & pavement Marking Signals & Geometrics Signing Design SURVEYING ENVIRONMENTAL ANALYSIS GPS (sample should include equipment list) Erosion and sedimentation control design Subsurface Utility Engineering Wetland, stream, and riparian buffer Route Location Surveys determinations Vangarde Surveys for threatened/endangered species Construction Surveys Permit application Archeological surveys HYDRAULICS Hydraulic Design - Highways Hydrology Storm Water Management * This prequalification page is for those firms who are interested in performing design on small projects for a division office. Contact Person: James W. Rand - 919/ Operations [email protected] 1537 Mail Service Center Raleigh, NC October 1, 1995 (Rev. 2/14/03) -18- PEFQUAL-1

20 Name & Title: Work Address: RÉSUMÉ (For key personnel that work and reside in NC only) Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization Active Registration: Year First Registered/Discipline Other Experience and Qualifications: Name & Title: Work Address: RÉSUMÉ (For key personnel that work and reside in NC only) Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization Active Registration: Year First Registered/Discipline Other Experience and Qualifications: Duplicate if necessary October 1, 1995 (Rev. 2/14/03) -19- PEFQUAL-1

21 Name & Title: Work Address: RÉSUMÉ (For key personnel that work and reside in NC only) Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization Active Registration: Year First Registered/Discipline Other Experience and Qualifications: Name & Title: RÉSUMÉ (For key personnel that work and reside in NC only) Work Address: Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization Active Registration: Year First Registered/Discipline Other Experience and Qualifications: Duplicate if necessary October 1, 1995 (Rev. 2/14/03) -20- PEFQUAL-1

22 ACTIVITIES FOR WHICH YOUR FIRM HAS PRIME RESPONSIBILITY List samples of work (prime & sub) your North Carolina office has performed in the past two years (i.e., NCDOT, municipal, private, etc.) DATE PROJECT AND TYPE OF WORK LOCATION NAME AND ADDRESS OF OWNER FEE COMPLETED TOTAL NUMBER OF PRESENT PROJECTS: TOTAL FEE: Duplicate if necessary October 1, 1995 (Rev. 2/14/03) -21- PEFQUAL-1

23 MOST RECENT ACTIVITIES FOR WHICH YOUR FIRM PERFORMED CONSTRUCTION ENGINEERING & INSPECTION List all work (prime & sub) your North Carolina office is presently performing (i.e., NCDOT, municipal, private, etc.) PROJECT AND TYPE OF WORK LOCATION NAME AND ADDRESS OF OWNER FEE COMPLETION DATE OF SERVICES TOTAL NUMBER OF PROJECTS: TOTAL FEE: Duplicate if necessary October 1, 1995 (Rev. 2/14/03) -22- PEFQUAL-1

24 FINANCIAL STATEMENT (For New and Reinstated Firms Only-Not Necessary for Updates) Balance Sheet as of, 20 Date A Corporation Firm Name A Partnership State in Which Incorporated Individual/Other TOTAL CURRENT ASSETS (Including cash, bid deposits, notes, receivable stocks, bonds, inventories, interest receivable, life insurance) TOTAL CURRENT LIABILITIES (Judgments, accounts/notes payable owed to subcontractors, accrued taxes, accrued salaries and payrolls, accrued interest payable) TOTAL FIXED ASSETS (Net book value of plant, equipment and real estate) TOTAL FIXED AND LIABILITIES (Including mortgage on plant equipment and real estate and other liabilities) TOTAL ASSETS (Non-business real estate, land, building improvements, miscellaneous) NET WORTH (Including individual or partnership capital stock, surplus) TOTAL ASSETS TOTAL LIABILITIES AND NET WORTH October 1, 1995 (Rev. 2/14/03) -23- PEFQUAL-1

25 APPROVAL OF PERSONNEL The department shall have the right to approve or reject supervisory personnel assigned to a project. The engineers, business entity, or any subcontractor which are involved in the prequalification review process, listed on the Register of Qualified Firms, or are employed to provide services for the department shall not discuss employment opportunities or engage the services of any person or persons, now in the employment of the State without written and obtained consent of the department. The written consent must be requested through the employee's branch manager. In the event of engagement, the engineers, business entity, or their subcontractors shall restrict such person or persons from working on any of the contracted projects in which the person or persons were formerly involved in the contracting process while employed by the department. This restriction period shall be for the duration of the contracted project with which the person or persons was involved. "Involvement" shall be defined as active participation in any of the following activities: drafting the contract defining the scope of the contract selection of the firm for services negotiations of the cost of the contract (including calculating manhours or fees administration of the contract An exception to these terms may be granted when recommended by the Secretary and approved by the Board of Transportation. Failure to comply with the terms stated above in this section shall be grounds for termination of a contract(s) and/or not being considered for selection or work on future contracts for a period of one year. October 1, 1995 (Rev. 2/14/03) -24-

26 CONFLICT OF INTEREST ASSESSMENT 1. Has your firm or any principal been indicted, pled guilty, or been convicted of any offense that has resulted in your firm being debarred or suspended from performing work for any State, Local, or Federal Government during the past 5 years? Yes No If yes, attach a separate sheet(s) to this form giving the details involved. 2. Has any officer, employee, or member of your firm been indicted, pled guilty, or been convicted of any illegal restraints of trade (including collusive bidding), during the past 5 years? Yes No If yes, attach a separate sheet(s) to this form giving the details involved. 3. Has your firm or any officer, employee, or member of your firm been debarred for violation of various Public Contract Acts incorporating Labor Standards Provisions during the past 5 years? Yes No If yes, attach a separate sheet(s) to this form giving the details involved. 4. Is your firm under the protection of the bankruptcy court, has pending any petition in bankruptcy court or have you made an assignment for the benefit of creditors? Yes No 5. List the principal officers of your firm, or if not a corporation, the owners. If there are more than five (5), attach a list. Attach a brief résumé for each individual listed. Name Position Years of Experience Type of Work Experience List the principal members of your firm that are involved in the managerial or policy making decisions of your firm if other than those listed above. If there are more than five (5), attach a list. Attach a brief résumé for each individual listed. Name Position Years of Experience Type of Work Experience List all owners (including individuals, companies or corporations) of applicant's firm and the percent of ownership of each, and any successive parent entities. If there are more than five (5), attach a list. Include only owners who have 10% or more ownership. Name of Individual Percent of Ownership October 1, 1995 (Rev. 2/14/03) -25-

27 8. List each of the individuals identified in "7" who has financial interest in any other private consulting firm in this or another state; name the other firm and list the percentage of ownership of each owner listed in "10". If more than five (5), attach a list. Name of Individual or Firm Name of Other Firm Percent of Ownership List any officer or member of the firm in a management or policy making position listed in "7" and "8" who also is an officer or serves in the management of any other private consulting firm in this state or any other state. List the officer or manager and the firm as well as the position in the other firm. If more than five (5), attach a list Name of Individual Name of Firm Position Held 10. List all affiliates of the private consulting firm including, but not limited to: (1) joint ventures, (2) subsidiaries, (3) parent company, (4) companies owned or controlled by the parent company, (5) any company or firm having some mutual owners as the applicant which does business with the applicant. If more than five (5), attach a list Name of Firm Address Relationship 11. List major creditors of the private consulting firm, of its owners, and of all of its affiliates with normal banking relationships. If more than five (5), attach a list. Name Address List major creditors (or endorsers) of the private consulting firm, of its owners, and of all of its affiliates other than normal banking relationships that may have control over the firm. If more than five (5), attach a list. Name Address October 1, 1995 (Rev. 2/14/03) -26-

28 List any substantial landowners with which the private consulting firm, its owners, and its affiliates have a relationship. If more than five (5), attach a list Name Address Relationship *************************************************************************************************** Firm Name By: Title: STATE OF COUNTY OF On this day of, 20, personally appeared before me (Official of Firm) for (Firm Name) who signed the foregoing affidavit in my presence and made oath to the truth of the statement herein contained. Name of Notary My commission expires October 1, 1995 (Rev. 2/14/03) -27-