NYSDOT Mentor-Protégé Program
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Primary Business Address
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Website URL
Mentor Application
Please enter and fully complete the information requested below to apply as a Mentor in NYSDOT's Mentor-Protégé Program.
Business Phone Number
Please enter a valid phone number.
Your Name (Primary Contact)
First Name
Last Name
Your Email
Your Phone Number
Please enter a valid phone number.
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
Business Owner's Phone Number
Please enter a valid phone number.
Legal Structure:
Corporation
Partnership
Sole Proprietorship
Other
Principals legally authorized to bind the business (provide full names of all that apply and their respective titles):
Are you a Construction Contractor or an Engineering Design Consultant?
Construction Contractor
Engineering Consultant
Other
List the number of your business' employees.
Full-Time
Part-Time
Number of Personnel
List the names and construction/engineering experience of your key personnel:
Attach additional sheets or resumes for key personnel if necessary:
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Select the principal type(s) of work performed by the business:
Design-Build
Construction (heavy/highway, Demolition, Concrete)
Engineering (Civil, Geotechnical, Structural)
Landscaping
Other Engineering (Traffic, Electrical, Environmental)
Planning/Surveying
Trades (Electrical, Mechanical, etc.)
Other
Has the firm previously worked or currently works with NYSDOT on any projects?
Yes
No
Provide your bonding information:
Provide business annual gross receipts for the last three (3) years:
Annual Gross Amount
2023
2022
2021
Please list up to five (5) of the business' COMPLETED (in the past 5 years) or ONGOING NYSDOT projects:
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)
DBE Subs Used in Project
Claims as a Result of Project
List any business and/or industry/professional organizations in which you (and/or your firm) belong:
List the area(s) of expertise your firm will provide to a Protégé through this Program (select all that apply):
Understanding Construction Documents (Blueprint Reading/Estimating)
Scheduling
Construction Project Management
Understanding Contracts
Surety Bonding & Insurance
Accounting & Financial Management
Marketing
Other
Provide the number of hours your firm is prepared to devote per month by key personnel toward direct work with a Protégé firm (5 hour minimum per month).
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
Signature
Date
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Month
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Day
Year
Date
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