North Carolina Department of Transportation
Private Consulting Firm Qualifications Package
NAME OF FIRM DATE STATE
YEAR ESTABLISHED
CORPORATE ADDRESS A/C & TEL. NO.
Physical Address: Mailing Address: ( )
FAX NO. ( )
NORTH CAROLINA BRANCH OFFICE(S) A/C & TEL. NO.
Physical Address: Mailing Address: ( )
FAX NO. ( ) CONTACT PERSON
Corporate: NC Branch:
A/C & TEL NO. FAX NO. A/C & TEL NO. FAX NO.
( ) ( ) ( ) ( )
e-mail address: e-mail address:
This application is based on the following factors: (Check appropriate designation)
CERTIFIED TOTAL EMPLOYEES ORGANIZATION TYPE OF APPLICATION DBE IN NC IN FIRM Individual ¨ New ¨ Yes ¨ Total Employees in
Firm Partnership ¨ Updated ¨ No ¨
Total Employees in Corporation ¨ Reinstatement ¨ (If yes, attach a copy NC Offices
of NCDOT certification letter)
Total PE’s in NC Offices
FEDERAL TAX IDENTIFICATION NUMBER
Total LG’s in NC Offices
Total PLS’s in NC DATE OF REGISTRATION AND REGISTRATION NUMBER WITH Offices
SECRETARY OF STATE’S OFFICE DATE NUMBER (if applicable)
FIRM REGISTERED WITH NC STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND LAND SURVEYORS
Yes ¨ License Number No ¨ (If yes, attach copy of latest certificate or renewal letter from Board)
FIRM REGISTERED WITH NORTH CAROLINA BOARD FOR LICENSING OF GEOLOGISTS Yes ¨ License Number
No ¨ (If yes, attach copy of latest certificate or renewal card from Board)
I certify the information contained within this application is accurate. Submission of false information is cause for denial of prequalification with the North Carolina Department of Transportation.
NAME OF FIRM OR INDIVIDUAL SUBMITTING APPLICATION NAME AND TITLE OF PERSON SIGNING:
Signature Date
* This form can also be found at our web site:
www.doh.dot.state.nc.us/guidelines
(Click on Consultant Specific…PEF Qualifications - Prequalifications Form)CORPORATE HEADQUARTERS Highway Design Branch NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental Draftsmen/CADD Soils Engineers Engineers Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental Draftsmen/CADD Soils Engineers Engineers Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: If new firm, or existing firm adding new area of expertise, send a sample of work for each new area marked.
ROADWAY DESIGN GEOTECHNICAL SERVICES
Rural Roadway Design Laboratory Testing Services Urban Roadway Design Drilling Services
Interchange Design Engineering Services (sample should include MicroStation & GEOPAK
capabilities)
SURVEYING ENVIRONMENTAL SERVICES
GPS (sample should include equipment list) Hazardous Waste Site Analysis
SUE Preliminary Site Assessment
Route Location Surveys Detailed Site Reconnaissance/Site
Vangarde Sampling
Laboratory Services
PHOTOGRAMMETRY Remediation Services
Photogrammetric Services Underground Storage Tank Analysis
Aerial Photography Services Site Assessment (sample should include equipment list) Tank Removal/Disposal
BRIDGE DESIGN CSA/CAP
Bridges - Spans under 200’ Laboratory Services Bridges - Spans over 200’ Site Remediation Services
HYDRAULICS UTILITIES
Hydraulic Design - Bridges & Box Culverts Utilities b y Others (Plans)
Hydraulic Design - Highways Utility Construction (Plans, Specs, & Estimates) Hydrology
Storm Water Management OTHER
Scour Visualization
Safety & Health
CORPORATE HEADQUARTERS Highway Design Branch - Soils and Foundation Design NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists
Civil Engineers Hydraulics Engineers Draftsmen/CADD Engineering Technicians
Geotechnical Engineers Surveyors
Safety & Health
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists
Civil Engineers Hydraulics Engineers Draftsmen/CADD Engineering Technicians
Geotechnical Engineers Surveyors
Safety & Health
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: If new firm, or existing firm adding new area of expertise, send 2 samples of work for each new area marked to show your expertise with State DOTs.
GEOTECHNICAL ENGINEERING SERVICES
DESIGN SERVICES
TESTING SERVICES
(Submit complete design reports, list of latest design software)
(Submit complete testing reports, list of latest equipment and software)
Deep and Shallow Foundation Design Pile Driving Analyzer
Retaining Walls Crosshole Sonic Logging (CSL)
Soil Nail Walls (SNW) Pile Integrity Test (PIT)
Tieback Walls Statnamic
Pile Panel Walls Osterberg Load Cell
MSE Walls Static Load Test
Cantilever, Fabric Walls Drilled Pier Inspection Device
Other (SID)
Vibration Monitoring
Soil Improvements Other
Slope Stability and Embankment
Settlements Design & Analysis
Landslides mitigation and Analysis
Rock Slope Design and Analysis
Tunnel Design
OTHER (for both) Safety & Health
Contact Person: Nancy L. Gay - 919/250-4001 Highway Design Branch
ngay@dot.state.nc.us 1584 Mail Service Center Raleigh, NC 27699-1584
CORPORATE HEADQUARTERS Construction Services NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Construction Technicians Surveyors Civil Engineers Cost Estimators Transportation Claims Analysts Draftsmen/CADD Engineers CPM Schedulers Soils Engineers Safety & Health Construction Managers Structural Engineers
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Construction Technicians Surveyors Civil Engineers Cost Estimators Transportation Claims Analysts Draftsmen/CADD Engineers CPM Schedulers Soils Engineers Safety & Health Construction Managers Structural Engineers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
CONSTRUCTION
Roadway Construction Engineering & Construction Contract Claim Analysis Inspection
Structures Construction Engineering & OTHER
Inspection Safety & Health
Contact Person: Patrick Riddle - 919/733-7174
priddle@dot.state.nc.us
Contractual Services Section 1543 Mail Service Center Raleigh, NC 27699-1543
CORPORATE HEADQUARTERS Traffic Engineering & Safety Systems Services
NUMBER OF PERSONNEL BY DISCIPLINE:
(If individual has more than one discipline, list primary only.)Administrative Software Engineers
Civil Engineers GIS Staff
Draftsmen/CADD Structural Engineer Electrical Engineers Safety & Health
Transportation Engineers
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE:
(If individual has more than one discipline, list primary only.) Administrative Software EngineersCivil Engineers GIS Staff
Draftsmen/CADD Structural Engineer Electrical Engineers Safety & Health
Transportation Engineers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS
PREQUALIFICATION:
TRAFFIC ENGINEERING
OTHER
Traffic Control & Pavement Marking Safety & Health
Signals & Geometrics
Sign Design
Signal System Design
Congestion Management Strategies
Traffic Data Collection
Intelligent Transportation Systems
Signal System Timing Development &
Implementation
Signal Equipment Design/Application
Contact Person: Kenneth W. Ivey, PE - 919/715-7736
kwivey@dot.state.nc.us
Traffic Engineering Branch 1561 Mail Service Center Raleigh, NC 27699-1561
CORPORATE HEADQUARTERS Project Development & Environmental Analysis NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air Public Involvement Civil Engineers Quality Specialists Specialists
Draftsmen/CADD Community Planners GIS
NEPA/SEPA Practitioners Architectural Historians Environmental Transportation Planners Soil Scientists Engineers Archaeologists Biologists Safety & Health
Sociologists
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air Public Involvement Civil Engineers Quality Specialists Specialists
Draftsmen/CADD Community Planners GIS
NEPA/SEPA Practitioners Architectural Historians Environmental Transportation Planners Soil Scientists Engineers Archaeologists Biologists Safety & Health
Sociologists
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
PROJECT PLANNING OFFICE OF NATURAL ENVIRONMENT
Preparation of NEPA/SEPA Environmental (ONE)
Documents Threatened & Endangered Species Survey
& Studies
OFFICE OF HUMAN ENVIRONMENT Ecological & Biotic Community Studies
(OHE) Wetland and Stream Delineation
Public Involvement Wetland, Stream, and Buffer Permitting Indirect & Cumulative Impacts Assessment Wetland Mitigation Site Planning Archaeological Resource Surveys Wetland Mitigation Site Design and Historic Architectural Surveys of Standing Construction Oversight
Structures (Buildings & Bridges) Stream Biological Monitoring Traffic Noise Analysis Stream Mitigation Site Plan Air Quality Analysis Stream Mitigation Site Design and Community Impact Assessment & Construction Oversight
Environmental Justice Freshwater Mussel Surveys Safety and Health
Contact Persons: (919) 733-7844 Pam Rogers x 219, Beth Harmon x 312, Carl Goode 250-4092
Progers@dot.state.nc.us (Project Plannin g)
Bharmon@dot.state.nc.us (Natural Environment)
Cgoode@dot.state.nc.us (Human Environment) Project Development & Environmental Analysis 1548 Mail Service Cen ter
CORPORATE HEADQUARTERS GIS NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Surveyors (PLS)
Cartographers Safety & Health
Database Programmers Drafting Technicians GIS Analysts GIS Programmers GIS Technicians
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Surveyors (PLS)
Cartographers Safety & Health
Database Programmers Drafting Technicians GIS Analysts GIS Programmers GIS Technicians
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
Cartography Linear Referencing System Development
Drafting Remote Sensing Application Development
Environmental Data Collection Remote Sensing Data Collection
GIS Analysis Remote Sensing Data Processing
GIS Application Development (Programming) Spatial Database Applications GIS Data Conversion Spatial Database Development GIS Data Validation Transportation Data Collection GIS - Transportation Planning Applications Vehicle Routing
GPS Data Collection Video Logging
GPS Application Development (Programming) OTHER
Safety & Health Internet GIS Application Development
Linear Referencing System Applications
Contact Person: Forrest Robson, PE - 919/250-4188 x204
frobson@dot.state.nc.us
Geographic Information Systems 1587 Mail Service Center
CORPORATE HEADQUARTERS Bridge Maintenance NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Hydraulics Engineers
Civil Engineers Soils Engineers
Bridge Inspectors Bridge Engineers
Bridge Analysts Surveyors
Draftsman/CADD Environmental Engineers Electrical Engineers Safety & Health
Geologists
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Hydraulics Engineers
Civil Engineers Soils Engineers
Bridge Inspectors Bridge Engineers
Bridge Analysts Surveyors
Draftsman/CADD Environmental Engineers Electrical Engineers Safety & Health
Geologists
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: NBIS Municipal Bridge Inspection OTHER
Route Location Surveys Safety & Health Bridge Design - Spans under 200'
Hydraulic Design - Bridges & Box Culverts
Hydrology Scour
Geotechnical Laboratory Services Geotechnical Drilling Services Geotechnical Engineering Services Erosion and Sediment Control Stormwater Management
Hydraulic Design - Open Channels Stream Restoration - Mitigation Wetland Mitigation
Contact Person: John Emerson, PE - 919/733-4362 x13
jemerson@dot.state.nc.us
Bridge Maintenance Unit 1565 Mail Service Center Raleigh, NC 27699-1565
CORPORATE HEADQUARTERS Materials & Tests NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Lumber Inspectors
Biologists Safety & Health
Certified Welding Inspectors Chemists
Other Metals and Coatings Inspectors
OFFICE LOCATIONS
LOCATION OF OFFICES THAT WILL PROVIDE SERVICES
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: Laboratory Services
Water/Wastewater/Soil/Sludge
Inspection Services
Inspection of Metal Products Inspection of Wood Products
OTHER
Safety & Health
Contact Person: Jack E. Cowsert, PE - 919/733-7088
jcowsert@dot.state.nc.us
Materials & Tests Unit
1564 Mail Service Center
Raleigh, NC 27699-1564
CORPORATE HEADQUARTERS Pavement Management NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Safety & Health
Pavement Design Pavement Analysis Pavement Distress Identification Pavement Management
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Safety & Health
Pavement Design Pavement Analysis Pavement Distress Identification Pavement Management
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
Pavement Design OTHER
Pavement Condition Surveys Safety & Health Pavement Analysis
Pavement Management Systems Pavement Deflection Testing & Backcalculation
Skid Testing
Profilometer & Reporting Ground Penetrating Radar & Analysis
Contact Person: Jerry Blackwelder, PE - 919/250-4094
jblackwelder@dot.state.nc.us
Pavement Management Unit 1593 Mail Service Center Raleigh, NC 27699-1593
CORPORATE HEADQUARTERS Safety & Loss Control NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Environmental Engineers Safety Engineers Industrial Hygienist
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Environmental Engineers Safety Engineers Industrial Hygienist
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
ENVIRONMENTAL SERVICES OTHER
Hazardous Waste Site Analysis Safety & Health Preliminary Site Assessment
Detailed Site Reconnaissance/Site Sampling
Laboratory Services Remediation Services
Underground Storage Tank Analysis
Site Assessment Tank Removal/Disposal CSA/CAP
Laboratory Services Site Remediation Services
Contact Person: R. K. Andrews, Jr., CSP - 919/250-4200 x241
rkandrews@dot.state.nc.us
Safety & Loss Control 1594 Mail Service Center Raleigh, NC 27699-1594
CORPORATE HEADQUARTERS Statewide Planning NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Public Involvement
Civil Engineers Specialists
GIS Safety & Health
Transportation Engineers
Land Use Planners
Environmental Specialists
Transportation Modelers
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Public Involvement
Civil Engineers Specialists
GIS Safety & Health
Transportation Engineers
Land Use Planners
Environmental Specialists
Transportation Modelers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
Transportation Planning OTHER
Traffic Forecasting Safety & Health Model Development
Transportation Plan Development Functional Design Public Involvement Environmental Analysis
Contact Persons: Mike Bruff, PE - 919/733-4705 / Laura Cove, PE - 919/715-5737
bruff@dot.state.nc.us
lcove@dot.state.nc.us
Statewide Planning Branch 1554 Mail Service Center Raleigh, NC 27699-1554
Roadside Environmental -
CORPORATE HEADQUARTERS Soil & Water Engineering Section
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Safety & Health
Civil Engineers Agricultural Engineers Hydraulic Engineers Environmental Engineers Draftsmen/CADD
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Safety & Health
Civil Engineers Agricultural Engineers Hydraulic Engineers Environmental Engineers Draftsmen/CADD
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: Erosion and Sediment Control OTHER
Hydrology Safety & Health
Stormwater Management
Hydraulic Design - Open Channels Stream Restoration/Mitigation Wetland Mitigation
Contact Person: David B. Harris - 919/733-2920
davidharris@dot.state.nc.us
Roadside Environmental UnitSoil and Water Engineering Section 1557 Mail Service Center
Roadside Environmental -
CORPORATE HEADQUARTERS Environmental Operations Section
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Draftsman/CADD
Environmental Engineers Safety & Health
Geologists Certified Hazardous Materials Managers Civil Engineers Surveyors
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Draftsman/CADD
Environmental Engineers Safety & Health
Geologists Certified Hazardous Materials Managers Civil Engineers Surveyors
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
ENVIRONMENTAL SERVICES OTHER
Hazardous Waste Site Analysis Safety & Health Preliminary Site Assessment
Detailed Site Reconnaissance/Site Sampling
Laboratory Services Remediation Services
Underground Storage Tank Analysis
Site Assessment Tank Removal/Disposal CSA/CAP
Laboratory Services Site Remediation Services
Contact Person: T. C. Niver, PG, CHMM - 1-888-457-0512
tniver@dot.state.nc.us
Roadside Environmental Unit Environmental Operations Section 4809 Beryl Road
Rail Division - CORPORATE HEADQUARTERS Engineering & Safety and Operations Branches NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Environmental
Civil Engineers Hydraulics Engineers Engineers Draftsmen/CADD Soils Engineers Architects Traffic Engineers Bridge Engineers Construction Railroad Engineers Surveyors Inspectors Roadway Engineers Photogrammetrists Safety & Health
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Environmental
Civil Engineers Hydraulics Engineers Engineers Draftsmen/CADD Soils Engineers Architects Traffic Engineers Bridge Engineers Construction Railroad Engineers Surveyors Inspectors Roadway Engineers Photogrammetrists Safety & Health
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
RAIL-HIGHWAY CROSSING OPERATIONS FACILITIES DESIGN
Traffic Separation Studies and Crossing AND MANAGEMENT Evaluation Studies Passenger Station Design
Railroad Crossing Signal and Traffic Historic Passenger Station Renovations Engineering Services Passenger Platforms
RAIL ENGINEERING Construction Administration
Track Design, Survey, and Layout Maintenance Facility Railroad Signal System Plans Rail Facilities Review of Engineering Drawings, Standards Rail Sidings
and Specifications Landscape and Streetscape Design Rail Construction Project Inspection and
Management OTHER
Boundary and Location Surveys Safety & Health Project Preliminary/Conceptual Plans and
Visualizations
Rail Corridor Maintenance Assessments, Surveys, and Lease Studies
Rail Corridor Traffic Modeling and Capacity/Feasibility Studies
Contact Person: Arthur Petteway, PE - 919/715-3689
apetteway@dot.state.nc.us
Rail Division (Engineering & Safety Branch) 1556 Mail Service Center
CORPORATE HEADQUARTERS Rail Division - Planning Branch NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air Bridge Engineers Civil Engineers Quality Specialists Public Involvement Draftsmen/CADD Architect Historians Specialists Transportation Engineers Geologists Transportation
Planners Hydraulic Engineers Modelers
Archaeologists Soils Engineers Environmental Biologists Railroad Engineers Engineers
Safety & Health NEPA/SEPA
Practitioners
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Traffic Noise & Air Bridge Engineers Civil Engineers Quality Specialists Public Involvement Draftsmen/CADD Architect Historians Specialists Transportation Engineers Geologists Transportation
Planners Hydraulic Engineers Modelers
Archaeologists Soils Engineers Environmental Biologists Railroad Engineers Engineers
Safety & Health NEPA/SEPA
Practitioners
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
PROJECT PLANNING ENVIRONMENTAL SERVICES
Route Location & Feasibility Studies Natural Resources
Preparation of Environmental Documents Ecological & Biotic Community Studies Rail Functional and Preliminary Design Threatened & Endangered Species Studies of Economic and Fiscal Impact of Investigation
Rail Related Activities Wetland and Stream Delineations Demand Modeling, Ridership, Revenue, Wetland and Stream Mitigation Operating Costs for Commuter and
Intercity Passenger Rail Operations Site Planning
Safety & Health
Train Performance and Rail Line Capacity Cultural Resources
Analysis Archaeological Resource Surveys Technical and Negotiation Assistance in Standing Historic Structure Surveys Securing Rail Lines or Corridors Traffic Noise Analysis
Air Quality Analysis
Full NEPA/SEPA Documentation
Environmental Permits Acquisition
Contact Person: Arthur Petteway, PE - 919/715-3689 (See page 13 for
apetteway@dot.state.nc.us
mailing address)CORPORATE HEADQUARTERS Program Development NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative
Traffic Noise & Air Quality Specialists
Public Involvement Specialists
Civil Engineers Community Planners GIS
Draftsmen/CADD Architectural Historians
Environmental Engineers Transportation Engineers Soil Engineers Safety & Health Transportation Planners Biologists
Hydraulics Engineers Archaeologists
NC OFFICE/S
(Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative
Traffic Noise & Air Quality Specialists
Public Involvement Specialists
Civil Engineers Community Planners GIS
Draftsmen/CADD Architectural Historians
Environmental Engineers Transportation Engineers Soil Engineers Safety & Health Transportation Planners Biologists
Hydraulics Engineers Archaeologists
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
PROJECT PLANNING NATURAL ENVIRONMENTAL SERVICES
Route Location, Preliminary Design & Feasibility Studies
Threatened & Endangered Species Survey & Studies
Preparation of NEPA/SEPA Environmental
Documents Ecological & Biotic Community Studies Traffic Projections Wetland and Stream Delineation Highway & Signal Capacity Analysis Wetland and Stream Permitting Traffic Projections
Wetland Mitigation Site Planning and/or Construction
HUMAN ENVIRONMENTAL SERVICES Stream Biological Monitoring
Public Involvement Stream Mitigation Site Planning & Indirect & Cumulative Impacts Assessment
Restoration
Archaeological Resource Surveys Freshwater Mussel Surveys Historic Architectural Surveys of Standing
Structures (Buildings & Bridges)
Traffic Noise Analysis OTHER
Air Quality Analysis Safety & Health Community Impact Assessment &
Environmental Justice
Contact Persons: Derrick W. Lewis, PE - 919/733-3690 x350
dlewis@dot.state.nc.us
Program Development Branch 1534 Mail Service Center Raleigh, NC 27699-1534
CORPORATE HEADQUARTERS Equipment & Inventory Control Unit NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists
Civil Engineers Soils Scientists
Draftsmen/CADD Surveyors
Electrical Engineers Safety & Health Environmental Engineers
NC OFFICE/S
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists
Civil Engineers Soils Scientists
Draftsmen/CADD Surveyors
Electrical Engineers Safety & Health Environmental Engineers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
GEOTECHNICAL SERVICES OTHER
Laboratory Testing Services Safety & Health Drilling Services
Engineering Services
ENVIRONMENTAL SERVICES
Hazardous Waste Site Analysis
Preliminary Site Assessment Detailed Site Reconnaissance/Site Sampling
Laboratory Services Remediation Services
Underground Storage Tank Analysis
Site Assessment Tank Removal/Disposal CSA/CAP
Laboratory Services Site Remediation Services
Contact Persons: Eric Motzno - 919/733-2220 emotzno@dot.state.nc.us (Delivery) Equipment & Inventory Control Unit
4809 Beryl Road Raleigh, NC 27606
(Mail) 1566 Mail Service Center Raleigh, NC 27699-1566
CORPORATE HEADQUARTERS Division Design/Construct Limited Services
*
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental Draftsmen/CADD Soils Engineers Engineers Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental Draftsmen/CADD Soils Engineers Engineers Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
INDICATE TYPE OF PROJE CTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: If new firm, or existing firm adding new area of expertise, send a sample of work for each new area marked.
ROADWAY DESIGN TRAFFIC ENGINEERING
Rural Roadway Design Traffic Control & pavement Marking Urban Roadway Design Signals & Geometrics
(sample should include computer design Signing Design
capabilities -MicroStation & GEOPAK preferred)
SURVEYING ENVIRONMENTAL ANALYSIS
GPS (sample should include equipment list) Erosion and sedimentation control design Subsurface Utility Engineering Wetland, stream, and riparian buffer Route Location Surveys determinations
Vangarde Surveys for threatened/endangered species
Construction Surveys Permit application
Archeological surveys
HYDRAULICS
Hydraulic Design - Highways OTHER Hydrology
Storm Water Management
*
This prequalification page is for those firms who are
interested in performing design on small projects for a
division office.
Contact Person: James W. Rand - 919/733-7621 Operations
jrand@dot.state.nc.us 1537 Mail Service Center Raleigh, NC 27699-1537
RÉSUMÉ
(For key personnel that work and reside in NC only)
Name & Title: Work Address:
Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
RÉSUMÉ
(For key personnel that work and reside in NC only)
Name & Title: Work Address:
Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
RÉSUMÉ
(For key personnel that work and reside in NC only)
Name & Title: Work Address:
Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
RÉSUMÉ
(For key personnel that work and reside in NC only)
Name & Title: Work Address:
Years experience: With This Firm With Other Firms Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
ACTIVITIES FOR WHICH YOUR FIRM HAS PRIME RESPONSIBILITY
List samples of work (prime & sub) your North Carolina office has performed in the past two years (i.e., NCDOT, municipal, private, etc.) PROJECT AND TYPE OF WORK LOCATION NAME AND ADDRESS OF OWNER FEE
DATE COMPLETED
MOST RECENT ACTIVITIES FOR WHICH YOUR FIRM PERFORMED CONSTRUCTION ENGINEERING & INSPECTION
List all work (prime & sub) your North Carolina office is presently performing (i.e., NCDOT, municipal, private, etc.)
PROJECT AND TYPE OF WORK LOCATION NAME AND ADDRESS OF OWNER FEE COMPLETION
DATE OF SERVICES
FINANCIAL STATEMENT
(For New and Reinstated Firms Only-Not Necessary for Updates)
Balance Sheet as of , 20
Date
¨ A Corporation
Firm Name ¨ A Partnership State in Which Incorporated
¨ Individual/Other
TOTAL CURRENT ASSETS TOTAL CURRENT LIABILITIES
(Including cash, bid deposits, notes, receivable stocks, bonds, inventories, interest receivable, life insurance)
(Judgments, accounts/notes payable owed to subcontractors, accrued taxes, accrued salaries and payrolls, accrued interest payable)
TOTAL FIXED ASSETS TOTAL FIXED AND OTHER LIABILITIES
(Net book value of plant, equipment and real estate)
(Including mortgage on plant equipment and real estate and other liabilities)
TOTAL OTHER ASSETS NET WORTH
(Non-business real estate, land, building improvements, miscellaneous)
(Including individual or partnership capital stock, surplus)
TOTAL ASSETS
TOTAL LIABILITIES AND
APPROVAL OF PERSONNEL
The department shall have the right to approve or reject supervisory personnel assigned to
a project.
The engineers, business entity, or any subcontractor which are involved in the
prequalification review process, listed on the Register of Qualified Firms, or are employed to
provide services for the department shall not discuss employment opportunities or engage
the services of any person or persons, now in the employment of the State without written
and obtained consent of the department. The written consent must be requested through
the employee's branch manager.
In the event of engagement, the engineers, business entity, or their subcontractors shall
restrict such person or persons from working on any of the contracted projects in which the
person or persons were formerly involved in the contracting process while employed by the
department. This restriction period shall be for the duration of the contracted project with
which the person or persons was involved. "Involvement" shall be defined as active
participation in any of the following activities:
§
drafting the contract
§
defining the scope of the contract
§
selection of the firm for services
§
negotiations of the cost of the contract (including calculating manhours or fees
§
administration of the contract
An exception to these terms may be granted when recommended by the Secretary and
approved by the Board of Transportation.
Failure to comply with the terms stated above in this section shall be grounds for termination
of a contract(s) and/or not being considered for selection or work on future contracts for a
period of one year.
CONFLICT OF INTEREST ASSESSMENT
1. Has your firm or any principal been indicted, pled guilty, or been convicted of any offense that
has resulted in your firm being debarred or suspended from performing work for any State,
Local, or Federal Government during the past 5 years?
Yes
No If yes, attach a separate
sheet(s) to this form giving the details involved.
2. Has any officer, employee, or member of your firm been indicted, pled guilty, or been convicted
of any illegal restraints of trade (including collusive bidding), during the past 5 years?
Yes
No If yes, attach a separate sheet(s) to this form giving the details involved.
3. Has your firm or any officer, employee, or member of your firm been debarred for violation of
various Public Contract Acts incorporating Labor Standards Provisions during the past 5 years?
Yes
No If yes, attach a separate sheet(s) to this form giving the details involved.
4. Is your firm under the protection of the bankruptcy court, has pending any petition in bankruptcy
court or have you made an assignment for the benefit of creditors?
Yes
No
5. List the principal officers of your firm, or if not a corporation, the owners. If there are more than
five (5), attach a list. Attach a brief résumé for each individual listed.
Name Position Years of Experience Type of Work Experience 1. 2. 3. 4. 5.
6. List the principal members of your firm that are involved in the managerial or policy making
decisions of your firm if other than those listed above. If there are more than five (5), attach a
list. Attach a brief résumé for each individual listed.
Name Position Years of Experience Type of Work Experience 1. 2. 3. 4. 5.
7. List all owners (including individuals, companies or corporations) of applicant's firm and the
percent of ownership of each, and any successive parent entities. If there are more than five (5),
attach a list. Include only owners who have 10% or more ownership.
Name of Individual Percent of Ownership
1. 2. 3. 4. 5.
8. List each of the individuals identified in "7" who has financial interest in any other private
consulting firm in this or another state; name the other firm and list the percentage of ownership
of each owner listed in "10". If more than five (5), attach a list.
Name of Individual or Firm Name of Other Firm
Percent of Ownership 1. 2. 3. 4. 5.
9. List any officer or member of the firm in a management or policy making position listed in "7" and
"8" who also is an officer or serves in the management of any other private consulting firm in this
state or any other state. List the officer or manager and the firm as well as the position in the
other firm. If more than five (5), attach a list.
Name of Individual Name of Firm Position Held
1. 2. 3. 4. 5.
10. List all affiliates of the private consulting firm including, but not limited to: (1) joint ventures, (2)
subsidiaries, (3) parent company, (4) companies owned or controlled by the parent company, (5)
any company or firm having some mutual owners as the applicant which does business with the
applicant. If more than five (5), attach a list.
Name of Firm Address Relationship
1. 2. 3. 4. 5.
11. List major creditors of the private consulting firm, of its owners, and of all of its affiliates with
normal banking relationships. If more than five (5), attach a list.
Name Address 1. 2. 3. 4. 5.
12. List major creditors (or endorsers) of the private consulting firm, of its owners, and of all of its
affiliates other than normal banking relationships that may have control over the firm. If more
than five (5), attach a list.
Name Address
1. 2.
3. 4. 5.
13. List any substantial landowners with which the private consulting firm, its owners, and its
affiliates have a relationship. If more than five (5), attach a list.
Name Address Relationship
1. 2. 3. 4. 5. *************************************************************************************************** Firm Name By: Title: STATE OF COUNTY OF
On this day of , 20 , personally appeared before me for
(Official of Firm) (Firm Name)
who signed the foregoing affidavit in my presence and made oath to the truth of the statement herein contained.
Name of Notary
