Massachusetts Dsb Application Form PDF Details

The Massachusetts DSB Application Form, updated in July 2016, serves as an essential document for firms aiming to undertake state projects within Massachusetts. This comprehensive form requires detailed information about the firm filing for the project, including the project name and location, the firm’s name, address, the name of the proposed project manager for both study and design phases if applicable, and the federal ID number. It also inquires about the date the firm and any predecessor firms were established, the names and addresses of other participating offices, and any parent company details. A unique feature of the form is its request for certification details, asking firms to indicate if they are certified as Minority, Woman, Minority Woman Business Enterprises, Service Disabled Veteran, or Veteran Owned Business Enterprises. Additionally, the form delves into the personnel composition of the prime firm, seeking specifics about the average number of employees in various disciplines over the preceding six months. Firms with joint ventures must disclose their history of collaboration, and the form also requires submission of an organizational chart detailing prime and sub-consultant personnel specifically requested in the advertisement. Moreover, a brief resume for these key personnel is necessary, emphasizing their qualifications and experience relevant to the advertised project. The form also prompts firms to enumerate current and relevant projects that best showcase their qualifications in the areas listed in the advertisement, for both the prime applicant or joint-venture members and any sub-consultants, thereby giving a profound insight into the firm's expertise and capability to handle state projects.

QuestionAnswer
Form NameMassachusetts Dsb Application Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other nameswbe, ma dsb form print, registr, ma dsb form

Form Preview Example

 

 

 

 

1. Project Name/Location for Which Firm is Filing:

 

 

 

2a. DSB #

 

 

 

 

Item #

 

 

 

Commonwealth of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Massachusetts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSB Application Form

 

 

 

 

 

 

 

 

 

 

2b. Mass. State Project #

 

 

 

 

 

 

(Updated July 2016)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3a.

Firm (Or Joint-Venture) - Name and Address Of Primary Office To Perform The Work:

3e. Name Of Proposed Project Manager:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Study:

(if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Design:

(if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3b. Date Present and Predecessor Firms Were Established:

 

 

 

 

3f. Name and Address Of Other Participating Offices Of The Prime Applicant, If Different From

 

 

 

 

 

 

 

 

 

 

 

 

Item 3a Above:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3c.

Federal ID #:

 

 

 

 

 

 

 

 

3g. Name and Address Of Parent Company, If Any:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3d.

Name and Title Of Principal-In-Charge Of The Project (MA Registration Required):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3h. Check Below If Your Firm Is Either:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) SDO Certified Minority Business Enterprise (MBE)

 

 

 

Email Address:

 

 

 

 

 

 

 

 

(2) SDO Certified Woman Business Enterprise (WBE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3) SDO Certified Minority Woman Business Enterprise (M/WBE)

 

 

 

Telephone No:

 

 

 

Fax No.:

 

 

 

 

(4) SDO Certified Service Disabled Veteran Owned Business Enterprise (SDVOBE)

 

 

 

 

 

 

 

 

 

 

 

 

(5) SDO Certified Veteran Owned Business Enterprise (VBE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Personnel From Prime Firm Included In Question #3a Above By Discipline (List Each Person Only Once, By Primary Function -- Average Number Employed Throughout The Preceding 6 Month

 

Period. Indicate Both The Total Number In Each Discipline And, Within Brackets, The Total Number Holding Massachusetts Registrations):

 

 

 

 

 

 

 

 

Admin. Personnel

 

 

(

 

)

Ecologists

 

(

 

)

Licensed Site Profs.

 

 

(

 

)

 

Other

 

 

(

 

)

Architects

 

 

(

 

)

Electrical Engrs.

 

(

 

)

Mechanical Engrs.

 

 

(

 

)

 

 

 

 

(

 

)

Acoustical Engrs.

 

 

(

 

)

Environmental Engrs.

 

(

 

)

Planners: Urban./Reg.

 

 

(

 

)

 

 

 

 

(

 

)

Civil Engrs.

 

 

(

 

)

Fire Protection Engrs.

 

(

 

)

Specification Writers

 

 

(

 

)

 

 

 

 

(

 

)

Code Specialists

 

 

(

 

)

Geotech. Engrs.

 

(

 

)

Structural Engrs.

 

 

(

 

)

 

 

 

 

(

 

)

Construction

 

 

(

 

)

Industrial Hygienists

 

(

 

)

Surveyors

 

 

 

 

(

 

)

 

 

 

 

(

 

)

Cost Estimators

 

 

(

 

)

Interior Designers

 

(

 

)

 

 

 

 

 

(

 

)

 

 

 

 

(

 

)

Drafters

 

 

(

 

)

Landscape Architects

 

(

 

)

 

 

 

 

 

(

 

)

 

Total

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Has this Joint-Venture previously worked together?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Updated July 2016

6.List ONLY Those Prime and Sub-Consultant Personnel Specifically Requested In The Advertisement. This Information Should Be Presented Below In The Form Of An Organizational Chart. Include Name Of Firm and Name Of The One Person In Charge Of The Discipline, With Mass. Registration Number, As Well As MBE/WBE Status, If Applicable:

User Agency

Prime Consultant

Principal-In-Charge

Project Manager for Study

Project Manager for Design

Discipline

(from advertisement)

Name Of Firm

Person In Charge Of Discipline

Mass. Registr. #

MBE/WBE Certified (If

Applicable)

Discipline

(from advertisement)

Name Of Firm

Person In Charge Of Discipline

Mass. Registr. #

MBE/WBE Certified (If

Applicable)

Discipline

(from advertisement)

Name Of Firm

Person In Charge Of Discipline

Mass. Registr. #

MBE/WBE Certified (If

Applicable)

Discipline

(from advertisement)

Name Of Firm

Person In Charge Of Discipline

Mass. Registr. #

MBE/WBE Certified (If

Applicable)

Updated July 2016

7.

Brief Resume of ONLY those Prime Applicant and Sub-Consultant personnel requested in the Advertisement. Include Resumes of Project Managers. Resumes should be consistent with the

 

 

persons listed on the Organizational Chart in Question # 6. Additional sheets should be provided only as required for the number of Key Personnel requested in the Advertisement and they must

 

be in the format provided. By including a Firm as a Sub-Consultant, the Prime Applicant certifies that the listed Firm has agreed to work on this Project, should the team be selected.

 

a.

Name and Title Within Firm:

 

 

 

a.

Name and Title Within Firm:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Project Assignment:

 

 

 

b.

Project Assignment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Name and Address Of Office In Which Individual Identified In 7a Resides:

 

c.

Name and Address Of Office In Which Individual Identified In 7a Resides:

 

 

 

 

MBE

 

 

 

 

MBE

 

 

 

WBE

 

 

 

 

WBE

 

 

 

SDOVBE

 

 

 

 

SDOVBE

 

 

 

VBE

 

 

 

 

VBE

d.

Years Experience: With This Firm:

 

With Other Firms:

 

 

d.

Years Experience: With This Firm:

 

With Other Firms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e.

Education: Degree(s) /Year/Specialization

 

 

 

e.

Education: Degree(s) /Year/Specialization

 

 

 

 

 

 

 

 

 

 

 

f.

Active Registration: Year First Registered/Discipline/Mass Registration Number

 

f.

Active Registration: Year First Registered/Discipline/Mass Registration Number:

 

 

 

 

 

 

 

g.

Current Work Assignments and Availability For This Project:

 

g.

Current Work Assignments and Availability For This Project

 

 

 

 

 

 

 

h.

Other Experience and Qualification Relevant To The Proposed Project: (Identify Firm By

 

h.

Other Experience and Qualification Relevant To The Proposed Project: (Identify Firm By

 

 

Which Employed, If Not Current Firm):

 

 

 

 

Which Employed , If Not Current Firm):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Updated July 2016

Current and Relevant Work By Prime Applicant Or Joint-Venture Members. Include ONLY Work Which Best Illustrates Current Qualifications In The Areas Listed In The DSB Advertisement (List

8a. Up To But Not More Than 5 Projects).

a.

Project Name and Location

b. Brief Description Of Project and

c. Client’s Name, Address and Phone

d. Completion

e. Project Cost (In Thousands)

 

Principal-In-Charge

Services (Include Reference To Areas

Number. Include Name Of Contact Person

Date (Actual

Construction

Fee For Work For

 

 

Of Experience Listed In DSB

 

Or Estimated)

 

 

 

Costs(Actual, Or

 

 

 

Which Firm Was

 

 

Advertisement)

 

 

 

 

 

 

Estimated If Not

 

 

 

 

Responsible.

 

 

 

 

 

 

 

 

 

 

Completed)

 

 

 

 

 

 

(1)

 

 

 

 

 

 

(2)

(3)

(4)

(5)

Updated July 2016

8b. List Current and Relevant Work By Sub-Consultants Which Best Illustrates Current Qualifications In The Areas Listed In The Advertisement (Up To But Not More Than 5 Projects For Each Sub- Consultant). Use Additional Sheets Only As Required For The Number Of Sub-Consultants Requested In The Advertisement and They Must Be In The Format Provided.

Sub-Consultant Name:

a.

Project Name and Location

b. Brief Description Of Project and

c. Client’s Name, Address and Phone Number

d. Completion

e. Project Cost (In Thousands)

 

Principal-In-Charge

Services (Include Reference To

(Include Name Of Contact Person)

Date (Actual

Construction

Fee for Work for

 

 

Areas Of Experience Listed In DSB

 

Or Estimated)

 

 

 

Costs (Actual, Or

 

 

 

Which Firm Was

 

 

Advertisement)

 

 

 

 

 

 

Estimated If Not

 

 

 

 

Responsible

 

 

 

 

 

 

 

 

 

 

Completed)

 

 

 

 

 

 

(1)

 

 

 

 

 

 

(2)

(3)

(4)

(5)

Updated July 2016

9.List All Projects Within The Past 5 Years For Which Prime Applicant Has Performed, Or Has Entered Into A Contract To Perform, Any Design Services For All Public Agencies Within The Commonwealth.

# of Total Projects:

 

# of Active Projects:

Total Construction Cost (In Thousands)

 

 

 

of Active Projects (excluding studies):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Role

Phases

 

 

 

Construction Costs

Completion Date

 

 

Awarding Authority (Include Contact Name and

(In Thousands)

P, C, JV

St., Sch., D.D.,

Project Name, Location and Principal-In-Charge:

(Actual or Estimated)

Phone Number)

(Actual, or

*

C.D.,A.C. *

 

 

(R)Renovation or (N)New

 

 

 

Estimated if Not

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

4.

5.

6.

7.

8.

9.

10.

*P = Principal; C = Consultant; JV = Joint Venture; St. = Study; Sch. = Schematic; D.D. = Design Development; C.D. = Con struction Documents; A.C. = Administration of Contract

Updated July 2016

10.Use This Space To Provide Any Additional Information Or Description Of Resources Supporting The Qualifications Of Your Firm And That Of Your Sub-Consultants For The Proposed Project. If Needed, Up To Three, Double-Sided 8 ½” X 11” Supplementary Sheets Will Be Accepted. APPLICANTS ARE ENCOURAGED TO RESPOND SPECIFICALLY IN THIS SECTION TO THE APPLICATION EVALUATION - PROJECT EXPERIENCE REQUESTED IN THE ADVERTISEMENT.

Be specific – No Boiler Plate

11.Professional Liability Insurance:

Name of Company

Aggregate Amount

Pol icy Number

Expiration Date

12.Have monies been paid by you, or on your behalf, as a result of Professional Liability Claims (in any jurisdiction) occurring within the last 5 years and in excess of $50,000 per incident? Answer YES or NO. If YES, please include the name(s) of the Project(s) and Client(s), and an explanation (attach separate sheet if necessary).

13.Name Of Sole Proprietor Or Names Of All Firm Partners and Officers:

Name

Title

MA Reg #

Status/Discipline Name

Title

MA Reg #

Status/Discipline

a.

 

 

d.

 

 

 

b.

 

 

e.

 

 

 

c.

 

 

f.

 

 

 

14.If Corporation, Provide Names Of All Members Of The Board Of Directors:

Name

Title

MA Reg #

Status/Discipline Name

Title

MA Reg #

Status/Discipline

a.

 

 

d.

 

 

 

b.

 

 

e.

 

 

 

c.

 

 

f.

 

 

 

15.Names Of All Owners (Stocks Or Other Ownership):

Name and Title

% Ownership

MA Reg.#

Status/Discipline Name and Title

% Ownership

MA Reg.#

Status/Discipline

a.

 

 

d.

 

 

 

b.

 

 

e.

 

 

 

c.

 

 

f.

 

 

 

16.I hereby certify that the undersigned is an Authorized Signatory of Firm and is a Principal or Officer of Firm. I further certify that this firm is a “Designer”, as that term is defined in Chapter 7C, Section 44 of the General Laws, or that the services required are limited to construction management or the preparation of master plans, studies, surveys, soil tests, cost estimates or programs. The information contained in this application is true, accurate and sworn to by the undersigned under the pains and penalties of perjury.

Submitted By

__________________________________________________

Printed Name and Title _______________________________

Date ____________

(Signature)

 

 

 

 

 

 

 

The following forms MUST be attached to only ONE (ORIGINAL Copy) application: 1. SDO Certification required for MBE/WBE Firms; 2. Sub-Consultant Acknowledgment.

Updated July 2016

DSB S-CA

Commonwealth of Massachusetts

Designer Selection Board SUB-CONSULTANT ACKNOWLEDGMENT

Project:

Applicant Designer:

Sub-consultant:

SUB-CONSULTANT ACKNOWLEDGMENT

The sub-consultant named above hereby certifies that it has been notified by the Applicant Designer that it has been nominated to perform work on the Applicant Designer’s team for the above Project, which is under consideration at the Designer Selection Board.

Signature of Sub-Consultant Duly Authorized Representative

Print Name and Title

Date

It is a requirement that all applicants supply this document signed, attached to the Original application, for each of the listed sub-consultants stating that they are aware and agree to being nominated by said applicant designer. Electronic signatures are accepted.

Updated July 2016

DSB Sub-Consultant Form