Ga Dot Letterhead Form – Fill Out and Use This PDF

Russell R. McMurry, P.E., Commissioner

One Georgia Center

600 West Peachtree Street, NW

Atlanta, GA 30308

(404) 631-1000 Main Office

PRIME CONTRACTOR APPLICATION

Thank you for your interest in becoming a qualified contractor to perform work on contracts with the Georgia Department of Transportation. You must complete and submit the following to become a qualified contractor.

DOT FORM 478	QUESTIONNAIRE
DOT FORM 477	CONTRACTOR’S FINANCIAL STATEMENT

FINANCIAL STATEMENTS (AUDIT, REVIEW OR COMPILATION) (Must not be more than 12 months old)

REFERENCE LETTERS (PAST JOB PERFORMANCE) (See instructions below)

If you have not performed work for this Department in the last five (5) years, you must submit three (3) reference letters from three (3) agencies or individuals you have completed work for in the past three (3) years. We are interested in the type of work performed, the quality of your services, whether the work was completed within the time allowed and the level of cooperation provided in completing the project. Address reference letters to: Mr. Marc Mastronardi, P.E., Chairman, Prequalification Committee Contractors and mail to the address in the closing paragraph.

To avoid a delay in processing your request, return the entire application (include all numbered pages from Forms 477 & 478) and answer each question. If the question does not apply, “NA” or “None Applicable” is an acceptable response. Failure to return each page or answer any portion of the application is considered an omission resulting in a non-compliantrequest.

Before submitting your request, refer to the checklist included with this package to make sure the application is complete and accurate. Return one original DOT Form 477, one original DOT Form 478, the original/bound financial statement prepared by your CPA and three (3) reference letters (if you have not completed work for GDOT) to the: Georgia

Department of Transportation, Construction Bidding Administration, 600 West Peachtree Street, NW, 11th Floor, Atlanta, GA 30308 or by email to ContractorPrequalification@dot.ga.gov. You can contact Contractor Prequalification by phone at

(404)631-1147. Again, thank you for your interest in Georgia’s bidding process and allowing us the opportunity to serve you.

Sincerely,

Marc Mastronardi, P.E. Chairman

Prequalification Committee-Contractors

MM:NF

Attachments (Checklist, DOT Forms 477 & 478)

Prime Contractor Application

Page 2

Rev. 09-18-2020

CHECK LIST

PRIME CONTRACTOR

CONTRACTOR’S FINANCIAL STATEMENT — DOT FORM 477

CONTRACTOR INFORMATION — PAGE 1

Applicants MUST provide the company’s full name, the state where the entity is registered, a mailing and shipping address, e-mail address, and check the box that describes how the entity is organized.

ADJUSTED NET WORTH CALCULATION — PAGE 2

Enter the appropriate amounts for assets, liabilities, plant and equipment corresponding to the amounts listed on pages 6 and 7.

AUDITOR’S REPORT — PAGE 3, 4 & 5

The Confidential Contractor’s Financial Statement, DOT Form 477 MUST be complete. There are no exceptions.

Financial information provided in DOT Form 477 must be based on a compiled, reviewed or audited financial statements (determined based on adjusted net worth- see GA Rules and Regulations Section 672-5) prepared by an independent Certified Public Accountant. The financial statement should not be more than twelve (12) months old when the application is mailed. You MUST submit the bound/original report prepared by your CPA along with your application. The original signature and license number of a partner in the firm or the firm’s name and license number must be provided on the opinion letter accompanying the financial statement.

NOTE: Accountants practicing in the state of Georgia MUST be duly licensed in the state or obtain a “Temporary Permit” to practice in Georgia from the Secretary of State as required by the Georgia State Board of Accountancy. You can download the application for the permit at www.sos.ga.gov.

Accountants practicing in the state other than Georgia or where the company headquarters is located must be registered with the State Board of Accountancy in that State.

BALANCE SHEETS AND SCHEDULES — PAGE 6, 7, 8, 9, 10, 11 & 12

Complete the Asset, Liabilities and Equity Sections of the balance sheets. Corresponding itemized schedules for line items C (1 thru 4), D, E, F, J (1 thru 2), and Q must be submitted to justify each line. We cannot verify balance sheet entries without the corresponding itemized schedules. Unless your plant and construction equipment (H) is categorized accurately, it will be subject to the 40% reduction applied to categories on lines I (1 thru 5) of DOT Form 477.

NAME AND ADDRESS OF OFFICERS REQUIRED & AFFIDAVITS — PAGE 13

Provide the names and addresses of officers for the titles listed—the officers’ address MUST be included. Complete the affidavit that is appropriate for the entity. The affidavit MUST be signed by an authorized officer of the company and notarized by a notary public. Corporations MUST affix the corporate seal. The signature MUST be original; DO NOT

SUBMIT A COPY OF THIS PAGE.

NOTE: Although entities with Limited Liabilities Company, Partnership and Individual status do not have to affix a seal; the entity MUST sign and provide the company’s full name.

Prime Contractor Application

Page 3

Rev. 09-18-2020

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PRIME CONTRACTOR

QUESTIONNAIRE — DOT FORM 478

GENERAL INSTRUCTIONS

The Questionnaire is in MS Word fill-in format. Form fields, drop-downs and check boxes are included in the form to make the document user friendly assist in preserving the original format. Use the tab or arrow keys to scroll through the form. Information can be type directly into “Text

Form”

fields. Single click in the “Drop-down”

Select One

box to open the field to make your selection. Single click in the “Check Box”

field to make selection(s). If you cannot download, open or convert the forms for use, email your concerns to dosby@dot.ga.gov.

CONTRACTOR INFORMATION — PAGE 1

Applicants MUST provide the company’s full name, the state where the entity is registered, a mailing and shipping address, e-mail address, the Federal Employer Identification Number (FEIN) and check the box that describes how the entity is organized. The name on the application MUST correspond with the name imprinted on your corporate seal (if a registered corporation) and the name that will appear on bids.

WORK CODE CLASSIFICATION — PAGE 2, 3 & 4

Applicants MUST select one Primary Work Class and as many Secondary Work Class(es) as applicable. You MUST also select the location/area where you generally perform work on page four (4).

ELECTRICAL CONTRACTORS ONLY — PAGE 5

Applicants seeking prequalification as an electrical contractor MUST be licensed by the Georgia Secretary of State or the appropriate licensing board in your state of residence. Provide the organization’s name and the electrician’s name, license number and year(s) of experience in roadway, sign or navigational lighting.

CHRONOLOGICAL HISTORY AND MANAGEMENT STRUCTURE — PAGE 6, 7 &8

The name and experience of all officers, supervisors and field personnel MUST be provided. Address ALL concerns stated on page eight (8) with a “YES,” “NO” or “NA” response.

PAST JOB PERFORMANCE — PAGE 9

Provide the name of the contracting agency, the location and type of work performed and the contract amount. Subcontractors MUST give the name of the prime contractor. Answer “YES” or “NO” to the questions in columns (E), (F) & (G) and explain the details in connection with all none or untimely completion of projects on page 13, item (12A).

FIXED ASSETS — PAGE 10, 11 & 12

ALL fixed assets MUST be itemized and stated at BOOK VALUE (cost less depreciation). The QUANTITY, DESCRIPTION and AGE of the items MUST also be included on the schedule. Summarize the assets according to category/type of assets. Include “Land and Buildings” on page. Links to Excel spread sheets are included to the left of the TOTAL$ line on pages eight and nine to assist in itemizing the assets. Tabs for attachments are included in each workbook to allow for additional sheets. You may prepare and submit your own attachments as long as the information required in our format is included on the attachment. If you do not own equipment, your MUST submit a “Lease Agreement” with a itemized schedule of the items available for use from the leasing agent on page ten.

CLAIMS, LIQUIDATED DAMAGES, INSURANCE, ANTITRUST VIOLATIONS AND COLLUSION — PAGE 13 & 14

Complete (12A & B) if applicable and read the requirement for “Workers Compensation Insurance. An authorized officer of the company MUST sign and provide his/her official title.

ENTITY, OFFICERS AND CORPORATE AND NOTARY SEALS — PAGE15

All applicants MUST complete this page according to the entity’s type and structure. Provide the name and title of all personnel authorized to sign/withdraw contract documents from the Department on behalf of the company. This page MUST be signed by an authorized officer and notarized by a notary public. Corporations MUST affix the corporate seal.

REFERENCE LETTERS — REMINDER

If you have not completed work for this agency in the last five years, forward three (3) reference letters from three (3) different agencies or individuals you have completed work for in the past three (3) years. The letter MUST be on the letterhead of the company giving the reference. We do not accept references by email unless they are on electronically formatted or scanned letterhead.