NYSDOT Mentor-Protégé Program
Protégé Application
Please enter and fully complete the information requested below to apply for enrollment as a Protégé in NYSDOT's Mentor-Protégé Program.
Business Name
Enter your business' name.
Primary Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Business Start Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Name (Primary Contact)
First Name
Last Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you the owner of the business?
Yes, sole owner
Yes, a partner or shareholder
No
Primary Business Owner's Name
First Name
Last Name
Business Owner's Email
example@example.com
Business Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Section 1 - Organization
What is the business' legal structure?
Corporation
Partnership
Sole Proprietorship
Other
List all additional principals legally authorized to bind the business:
List the number of the business' employees:
Rows
Full-Time
Part-Time
Number of Personnel
List the business' key personnel and their construction and/or engineering experience:
Upload key personnel's resumes as necessary:
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Select the primary type(s) of business:
Construction Contractor
Engineering Consultant
Supplier/Manufacturer of Construction Materials
Landscaping
Trucking/Hauling
Other
Please select your NAICS codes for the principal area(s) of work performed:
Select the NYS region(s) where the business performs work:
Region 1 - Capital District
Region 2 - Mohawk Valley
Region 3 - Central NY
Region 4 - Genesee Valley
Region 5 - Western NY
Region 6 - Southern Tier/Central NY
Region 7 - North Country
Region 8 - Hudson Valley
Region 9 - Southern Tier
Region 10 - Long Island
Region 11 - New York City
Select the type(s) of customers the business serves:
Public
Private/Commercial
Residential
Other
List all government agencies the business has worked with:
Does the business have a capabilities statement?
Yes
No
Upload your capabilities statement here:
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Do you and/or your business belong to any industry/professional or business organizations?
Yes
No
Please list all affiliated industry/professional and business organizations:
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Section 2 - Financial
Provide the business' annual gross receipts for the last three (3) years:
Rows
Annual Gross Amount
2023
2022
2021
What is the business' Experience Modification Rate (EMR)?
Provide your insurance information:
Provide your bonding information:
Does the business have a line of credit?
Yes
No
What is the credit amount?
Does the business have a credit and collection policy?
Yes
No
Describe the business' credit and collection policy.
List all major operating equipment your company owns or leases if applicable:
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Section 3 - Projects
Provide the following information for current work in progress (list NYSDOT projects first).
Rows
Project 1
Project 2
Project 3
Project 4
Project 5
Project Name
Customer Name
Customer Address
Customer Contact Name
Customer Phone Number
Customer Email
Type of Project
Contract Amount
Date of Completion
Status (Prime, Sub, or Joint Venture)
Name of Prime (if applicable)
Provide the following information of projects your firm has completed in the past two years (list NYSDOT projects first).
Rows
Project 1
Project 2
Project 3
Project 4
Project 5
Project Name
Customer Name
Customer Address
Customer Contact Name
Customer Phone Number
Customer Email
Type of Project
Contract Amount
Date of Completion
Status (Prime, Sub, or Joint Venture)
Name of Prime (if applicable)
[OPTIONAL] Upload project sheets with the information above as needed:
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Has the business or any of its key personnel participated in any business education, short courses offered by NYSDOT, or specialized education classes in the past 2 to 3 years?
Yes
No
List all business education, short courses, or specialized education classes the business or its key personnel participated in within the past 2-3 years:
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Section 4 - Mentor-Protégé
Has the business ever participated in a Mentor-Protégé Program before?
Yes
No
List all Mentor-Protégé Programs the business has participated in:
Select which area(s) the business would like assistance in, through the Mentor-Protégé Program:
Accounting & Financial Management
Access to Capital
Bonding & Insurance
Business Planning
Job Costing & Change Orders
Contract Management
Contract Plans & Specifications
Construction Equipment & Materials
Estimating
Human Resources
Marketing
Organization Structure
Personnel Management
Procurement
Project Management
Scheduling & Purchasing
Strategy Development
Take-Off & Estimating
Other
List the business' short term (next 12 months) goals and objectives:
List the business' long term (next 36 months) goals and objectives:
Why are you interested in joining NYSDOT's Mentor-Protégé program?
How do you see mentoring helping you improve operational efficiency or quality on your projects, or achieving growth?
Please share any additional thoughts or comments below:
I hereby declare that all statements made herein are true, accurate and complete to the best of my knowledge. I authorized the New York State Department of Transportation and/or its agents to gather such information (business or personal credit information) as deemed necessary for participation in this Program. By signing this form, I also certify that neither the business nor any of its owners has any outstanding tax liens. I agree to abide by all Program guidelines or inform appropriate NYSDOT officials if at any time I am unable or unwilling to do so.
Name
First Name
Last Name
Title
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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