(1) Name of Firm:

(2) Application of Qualification (check all that apply)

Indicate which categories of services the submitter wishes to be considered. One questionnaire may contain qualifying information for multiple categories, or at the discretion of the submitting firm, multiple questionnaires may be completed and submitted so long as different categories of services are indicated on each.

Prime Consultant Indicate those categories consultant can execute using its in-house staff.

Specialty Consultant Indicate category(ies) for which consultant is requesting to be pre-qualified.

Archeological and Historic Investigations Bridge Engineering Bridge Inspection and Rating CADD Services (including GIS) Construction Engineering and Inspection Construction Materials Testing Environmental Permitting Environmental Technical Services Estimating Field Survey and Survey Plot (including GPS) Geotechnical Services Hydrology and Bridge Hydraulics (including scour analysis) Landscaping and Erosion Control Design Lighting Design Petroleum and Hazardous Wastes Investigation and Remediation Public Involvement Right of Way (including Mapping and Operations) Roadway Engineering Signing and Pavement Marking Design Traffic Data Collection and Analysis Traffic Engineering (including Signal Design) Training and Facilitation Utility Coordination Other, Explain _________________

Archeological and Historic Investigations Bridge Engineering Bridge Inspection and Rating CADD Services (including GIS) Construction Engineering and Inspection Construction Materials Testing Environmental Permitting Environmental Technical Services Estimating Field Survey and Survey Plot (including GPS) Geotechnical Services Hydrology and Bridge Hydraulics (including scour analysis) Landscaping and Erosion Control Design Lighting Design Petroleum and Hazardous Wastes Investigation and Remediation Public Involvement Right of Way (including Mapping and Operations) Roadway Engineering Signing and Pavement Marking Design Traffic Data Collection and Analysis Traffic Engineering (including Signal Design) Training and Facilitation Utility Coordination Other, Explain _________________

(3) Primary Point of Contact (Name/Address/Phone/E-mail):

(4) Year Established (Company & Oregon Office):

(5) Main Office and Resources:

(a) Company Headquarters or Home Office (Address/Phone):

(b) Total number of personnel in Company (as of last quarter):

(c) Total number of technical professionals in Company (as of last quarter):

In Attachment A, please provide a maximum of 30 resumes, each with a maximum of 3 pages, of key technical personnel with potential assignment to the services selected for qualification and indicate at a minimum name, title, resident office, education, license/certification, project experience and total years of experience.

(6) Other Offices and Resources:

(a) Office locations in Oregon (Address/Phone):

· Total number of personnel per office location (as of last quarter):

· Total number of technical professionals per office location (as of last quarter):

(b) U.S. office locations outside of Oregon (Address/Phone):

· Total number of personnel per office location (as of last quarter):

· Total number of technical professionals per office location (as of last quarter):

(7) Parent Company Information if Applicable (Name/Address):

(8) Capacity of Firm:

(a) Annual Revenue (2002/2003/2004):

(b) Current backlog of work for next 12 months (in dollars):

(c) Current plans for growth within Oregon to accommodate OTIA III bridge work:

(9) Oregon Business License Number (If not available, please explain):

(10) DMWESB Certification:

Is your firm a DMWESB enterprise company as certified by the State of Oregon office of Minority, Women, and Emerging Small Businesses? (Yes/No/Certification Number) If responding as a Prime Consultant, please furnish past performance in meeting DMWESB goals on your three most recent bridge projects.

(11) QA/QC Program (Attach Quality Management Program in Attachment B):

(12) History of Litigation:

Describe active/pending lawsuits brought or defended by your firm within the past five years.

(13) Errors and Omissions Insurance:

(a) Insurer Information (Name/Address/Contact Name/Phone/Amount of Coverage)

(b) What are company’s current levels of E&O coverage? (Occurrence & Annual Aggregate)

(c) Can company obtain coverage of $5 million limit per claim with an annual aggregate limit in the amount not less than $10 million? (Yes/No):

(d) Provide history of errors & omissions claims and disposition (list all within past 10 years)

(14) Project Experience (Project data sheets to be included in Attachment C):

Please provide list of projects (10 maximum) performed in the last 10 years which best illustrate firm’s current qualifications relevant to this OBDP Request for Qualification information. For each project include project name, location, scope summary, service provided by firm, client name and contact name/phone, completion date, and firm’s original/final contracted amount.

(15) OPTIONAL - Other information (Include in Attachment D):

Submit other pre-qualification information relevant to considering your firm for work on the Oregon Bridge Delivery Program (maximum of 10 pages).

(16) OBDP Financial Questionnaire

Consultant must indicate below whether or not it’s responses to Consultant Pre-Qualification Questionnaire (excluding response to Item 16 above) may be made public. In order for consultant’s response to be binding, it must also initial response in space provided below.

q Make Public. _________ q Keep Confidential. _________

Initials Initials