Architect, Engineer, Related Services Annual

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					                                         Architect, Engineer, & Related Services
                                                Annual Certification Form
       Nebraska Department of Roads • Planning & Project Development Division • Attn: Agreements Engineer
                                                                                                                              DEPT. USE ONLY
                             1500 Hwy 2 • PO Box 94759 • Lincoln NE 68509-4759                                                Contractor No.:
 Purpose:                                               b. Firm’s Federal Identification Number,        6. Names, locations and total number of
 The policy of the State of Nebraska in                    or Social Security Number in absence            personnel for headquarters and branch
 procuring architectural, engineering and                  of Federal I.D. No.                             offices.
 related professional services, is to consider     2.   Date the firm was established under the         7. Total number of employees, by discipline,
 for such work only firms which are certified to        name shown in item 1.                              in the submitting office. While some
 complete such services.        This form is       3.   Type of ownership, or legal structure, of          personnel may be qualified in several
 provided for that purpose. Interested firms            the firm (sole proprietor, partnership,            disciplines, each person should be
 must complete and submit this form to the              corporation, joint venture, etc.)                  counted only once in accordance with
 Nebraska Department of Roads Agreements                                                                   his or her primary function.     Include
 Engineer at the address above.                         a. Certified Disadvantaged Business
                                                           Enterprise.                                     clerical personnel as “administrative.”
 Instructions:                                                                                             Write in any additional disciplines --
                                                   4.   Branches or subsidiaries of larger or              sociologists, biologists, etc., and the
 Standard Work Categories:                              parent companies, or conglomerates,                number of people for each in the spaces
                                                        should insert the name and address of the          provided.
 Please indicate the type(s) of work your firm
                                                        highest tier owner.
 is interested in doing in Nebraska by placing
                                                        Note: If the present firm is the successor      8. This completed form must be signed and
 a checkmark in the appropriate box or boxes.
                                                                to, or outgrowth of, one or more           dated by a principal of the firm.
 Numbers below correspond to numbers                            predecessor firms, show the
 contained on the form. Please type all                                                                 Note: Additional data, brochures, photos,
                                                                name(s) of former entity(ties) and            etc., should not accompany this form
 information.                                                   the year(s) of their original                 unless specifically requested.
 1. Submitting firm, address and zip code.                      establishment.
                                                   5.   Name, title, email address, telephone, and             The Agreements Engineer will
    a. Indicate whether this form is being
                                                        FAX number of two principals from the                  determine the firm’s eligibility for
       submitted on behalf of a parent firm or
                                                        submitting firm who may be contacted by                certification and acknowledge in
       a branch office. (Branch office sub-
                                                        the state.     Listed principals must be               writing within 30 days certification of
       missions must list only personnel in,
                                                        empowered to speak for the firm on policy              the firm or the reasons for denial.
       and experience of, that office.)
                                                        and contractual matters.
                                                         Standard Work Categories
 Professional Services                             107          Bridge Design                           Support Services
 100         Corridor Studies                                   A. Major                                200        Aerial Photography
                                                                B. Minor                                201        Aerial Photogrammetry
 101         Environmental Studies
                                                                                                        202        Engineering Surveying
             A. NEPA Studies                       108          Railroad Design                         203        Geodetic Surveying
             B. Other Environmental Studies        109          Construction Inspection                 204        Land Surveying
 102         Transportation Planning                            A. Bridge                               205        Materials Testing
 103         Traffic Operation Studies                                                                  206        Bituminous Design
                                                                B. Roadway                                         A. Surfacing
 104         Traffic Operation Design                           C. Traffic Control Devices                         B. Resurfacing
 105         Highway Design - Major                             D. Railroad Construction and            207        Geological Studies
             A. Rural                                              Improvement Projects                 208        Bridge
             B. Urban                                                                                              A. NBIS Bridge Inspections
                                                   110          Building Design and Inspection
                                                                                                                   B. Load Rating
 106         Highway Design - Minor                111          Electrical and Mechanical Design        209        Hydraulic and Hydrologic Studies
             A. Rural                              112          Railroad Planning                       Other Categories Not Listed:
             B. Urban                              113          Intelligent Transportation              300
                                                                Systems (ITS)
                                                                                                        301
                                                                                                        302
                                                                                                        303
                                                                                                        304

1. Firm Name and Address:                                                   1a. Submittal is for:

                                                                                                    Parent Company            Branch
                                                                            1b. Federal I.D. No. or Social Security No.:



DR Form 497, Sep 08
Name of Firm:
2. Year Present Firm Was Established:      3. Type of Ownership:                                       3a. Certified Disadvantaged Business Enterprise:

                                                                                                                           Yes         No
4. Name of Parent Company: (If not in 1. above)




5.Name, Title, Email Address, Telephone, and FAX Number of Principals to Contact:

(1)
(2)




6. Present Offices: (City, State and number of personnel in each office)




7. Personnel by Discipline: (Submitting Office)
      Administrative                  Economists                                Interior Designers                 Surveyors, RLS
      Architects                      Electrical Engineers                      Landscape Architect                Systems Engineers
      Biologists                      Engineering Technicians/Aides             Mechanical Engineers               Transportation Engineers
      Chemical Engineers              Environmental Scientists                  Planners: Urban/Regional
      Civil Engineers                 Estimators                                Sanitary Engineers
      Construction Inspectors         Geologists                                Social Scientists
      Drafters                        Hydrologists                              Soils Engineer                     Total Personnel in Submitting Office
      Ecologists                      Instrument/Rod/Chain Persons              Structural Engineers
7. The foregoing is a statement of facts. (Signature)        Typed Name and Title:                                               Date: