STATEMENT OF QUALIFICATION FORM FOR NON-ENGINEERING CONSULTANTS
The Statement of Qualification Form must be completed in full (please include one additional copy) for each specialty (discipline) in which your firm wishes to be considered. Additional information, resumes, brochures and a letter of interest should be returned to: Nevada Department of Transportation Attn: Agreement Services 1263 South Stewart Street, Room 101 Carson City, NV 89712 1. 2. 3. 4. 5. 6. 7. Date Prepared: Firm's Name: Firm's Address: Phone: Is your local office the main office: Year your firm was established: Year your local office was established: Location of: a. Main office: or branch office: FAX: or sole office?
State of Nevada Department of Transportation
b.
Local office:
8.
Year former firm(s) were established: a. b. c. d.
9.
Name, title, telephone number, mailing address and e-mail address of one principal in firm who may be contacted:
10.
List locations of other offices (no more than five [5]): Address a. b. c. d. e. Telephone No. of Personnel
Revised 04/09
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11.
Total employees presently employed: a. b. At your local (Northern Nevada) office: At your local (Southern Nevada) office: In your firm:
12.
By category, give the number of projects your firm is working on / has worked: Current/Active a. b. c. d. Public/Governmental Commercial Residential Other Last Five (5) Years
13.
Nevada Department of Transportation encourages the participation and utilization of minority and women-owned businesses. a. Is your firm certified as a minority-owned, women-owned or disabled veteran-owned business? Yes b. No Specify
If yes, by what government agency? (i.e.: Project Management, etc.)
14.
Specialty (Discipline):
The Nevada Department of Transportation periodically engages consultants to perform work of a specialized nature including (but not limited to) such areas as DBE Supportive Services, Claims Review, etc. I. Briefly describe your specialty (discipline), and the scope of the services that your firm provides. Use additional forms for any additional types of specialty work.
II.
Select three recent projects that have applicability to this service category, and list a reference that the NDOT may contact for each. PROJECT NAME REFERENCE TELEPHONE
Revised 04/09
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15.
List all professional, technical and key members on staff in your local office. Indicate YEARS OF EQUIVALENT-FULL-TIME EXPERIENCE per each of the areas of professional expertise listed below. (Duplicate additional sheets if needed) AREA(S) OF PROFESSIONAL EXPERTISE Enter: YEARS OF EQUIVALENT-FULL-TIME EXPERIENCE*
A B C D E F G OTHER
NAME
TITLE
EDUCATION
DG/YR
YEARS OF EXPERIENCE
LOCAL OFFICE FIRM CAREER TOTAL
(Reference Areas of Expertise codes below)
OTHERS (define below)
*(3= Career Total)
A. Structural Steel Fabrication Inspection B. Industrial Hygiene C. Safety and Loss Control D. Statewide Multimodal Planning E. ITS Inspection and Maintenance
Revised 03/09
F. Appraisal/Appraisal Review G.
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