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					                            Louisiana Economic Development (LED)
                                   Mentor-Protégé Program

                         PROFESSIONAL MENTOR APPLICATION

A Company that is interested in participating in the LED Mentor-Protégé Program must submit an
application for approval as a Mentor to the Louisiana Economic Development, Community
Outreach Services - Entrepreneurial Services, P. O. Box 94185, Baton Rouge, Louisiana
70804-9185. Interested firms must be accepted as a participating mentor prior to
negotiation of a mentor-protégé agreement.

The following application must be fully completed and certified as true and accurate by a current
officer of the Mentor Company.

1.      Mentor Information

Mentor Point of Contact

Company/Division Name

Contact Name

Position Title

Address



Year Company Established

Phone/Fax Numbers

E-mail/URL
State Licensing Board License
Number
2. Eligibility.

     YES         NO   Company is currently licensed with the Louisiana State Licensing Board.

    YES        NO Company is currently performing under at least one active approved
contracting or subcontracting plan negotiated with private, state or federal entities.

   YES           NO   Company is currently eligible for the award of private, state or federal
contracts.

     YES       NO Company is in “good standing” with the Secretary of State, and not in
violation of any state statutes, rules, or governing policies.




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3. Historical Background.
Company is (√):      Engineering Consultant             Engineering Sub-consultant

Specific Professional Expertise:

Company Special Status History (√):         DBE        SBA Certified 8(a)       Women-Owned
(If a graduated 8(a), please include graduation date.)

4.      Private Industry Contracts. List the total dollar amount of Private Industry contracts
received by the company during the two preceding years.

                               Total Private Industry Contracts
                Year                                           Year
$                                               $

5.     Private Industry Subcontracts. List the total dollar amount of Private Industry
subcontracts received by the company during the two preceding years.

                              Total Private Industry Subcontracts
                Year                                           Year
$                                                $

6.    State Agency Contracts. List the total dollar amount of State Agency contracts received
by the company during the two preceding years.

                                    Total State Agency Contracts
                Year                                               Year
$                                                  $

7.      State Agency Subcontracts. List the total dollar amount of State Agency subcontracts
received by the company during the two preceding years.

                                   Total State Agency Subcontracts
                Year                                              Year
$                                                   $

8.      Federal Agency Contracts. List the total dollar amount of other Federal Agency
contracts received by the company during the two preceding years.

                                   Total Federal Agency Contracts
                Year                                             Year
$                                                  $

9.     Total Federal Agency Subcontracts. List the total dollar amount of Federal Agency
subcontracts received by the company during the two preceding years.

                              Total Federal Agency Subcontracts
                Year                                         Year
$                                              $



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10.     Ability to Provide Developmental Assistance.
     YES          NO The company has the ability to provide developmental assistance such as,
but not necessarily limited to:

Training and Education for professional engineering supervisory personnel focusing on the
knowledge and skills needed to help them become: effective managers of people; time and
resources; effective business leaders; and aware of technical requirements necessary to provide
quality professional engineering services.

Typical subjects could include: Business management; Human resources; Professional service
agreement management; Engineering design processes and quality control management; and
Engineering construction administration processing and quality control management.

11.     Attachments.

      YES      NO Profit & Loss Statement for the last two company year-ends.
      YES      NO Representative list of completed contracts.


12.     Affidavit
The undersigned certifies that he/she is the duly authorized representative of the Mentor business
applicant identified herein and that the foregoing statements, including statements and data
provided herein, are correct, true, and include all material information necessary to qualify the
business entity identified herein as a Mentor in accordance with the Mentor-Protégé Tax Credit
Program Act of 2007 (Act 356 of 2007; La. 47:6026) and its Rules.

The undersigned understands that false statements, omissions, or material misrepresentations
will be grounds for denial of certification, decertification, and/or termination of participation in
the Mentor-Protégé Tax Credit Program.

The Louisiana Department of Economic Development agrees that any financial or proprietary
business information submitted pursuant to this Application which are in their nature and
designated as confidential and submitted for purposes of allowing Louisiana Department of
Economic Development to investigate or to examine the business of such private firm in
connection with the statutory duties of Louisiana Department of Economic Development, shall be
considered to be and maintained as confidential and proprietary information within the meaning
of LA. R.S. 44:4(3); and Louisiana Department of Economic Development shall use all reasonable
means to maintain such confidentiality, and shall not disclose such information to any third party
except as permitted in this Application or as required by law.

Signature                                                          Date


Name (Printed or Typed)                                            Title




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