Are you interested in obtaining financial assistance from the Massachusetts Department of Elementary and Secondary Education (DESE)? If so, then understanding how to complete the Massachusetts DS Benefits Application Form is essential. This comprehensive guide will take you step-by-step through every section of the application, ensuring that you provide all relevant information needed for successful completion. Learn important tips on how to prepare before beginning this form, as well as what documents are required upon submission. With our help, applying for MassDSB benefits doesn’t need to be a stressful experience; get everything taken care of today!
Question | Answer |
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Form Name | Massachusetts Dsb Application Form |
Form Length | 8 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 2 min |
Other names | wbe, ma dsb form print, registr, ma dsb form |
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1. Project Name/Location for Which Firm is Filing: |
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2a. DSB # |
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Item # |
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Commonwealth of |
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Massachusetts |
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DSB Application Form |
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2b. Mass. State Project # |
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(Updated July 2016) |
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3a. |
Firm (Or |
3e. Name Of Proposed Project Manager: |
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For Study: |
(if applicable) |
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For Design: |
(if applicable) |
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3b. Date Present and Predecessor Firms Were Established: |
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3f. Name and Address Of Other Participating Offices Of The Prime Applicant, If Different From |
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Item 3a Above: |
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3c. |
Federal ID #: |
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3g. Name and Address Of Parent Company, If Any: |
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3d. |
Name and Title Of |
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3h. Check Below If Your Firm Is Either: |
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(1) SDO Certified Minority Business Enterprise (MBE) |
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Email Address: |
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(2) SDO Certified Woman Business Enterprise (WBE) |
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(3) SDO Certified Minority Woman Business Enterprise (M/WBE) |
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Telephone No: |
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Fax No.: |
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(4) SDO Certified Service Disabled Veteran Owned Business Enterprise (SDVOBE) |
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(5) SDO Certified Veteran Owned Business Enterprise (VBE) |
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4. |
Personnel From Prime Firm Included In Question #3a Above By Discipline (List Each Person Only Once, By Primary Function |
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Period. Indicate Both The Total Number In Each Discipline And, Within Brackets, The Total Number Holding Massachusetts Registrations): |
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Admin. Personnel |
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Ecologists |
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Licensed Site Profs. |
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Other |
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Architects |
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Electrical Engrs. |
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Mechanical Engrs. |
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Acoustical Engrs. |
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Environmental Engrs. |
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Planners: Urban./Reg. |
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Civil Engrs. |
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Fire Protection Engrs. |
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Specification Writers |
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Code Specialists |
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Geotech. Engrs. |
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Structural Engrs. |
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Construction |
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Industrial Hygienists |
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Surveyors |
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Cost Estimators |
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Interior Designers |
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Drafters |
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Landscape Architects |
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Total |
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5. |
Has this |
Yes |
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No |
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Updated July 2016
6.List ONLY Those Prime and
User Agency
Prime Consultant
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 |
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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 |
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be in the format provided. By including a Firm as a |
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a. |
Name and Title Within Firm: |
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a. |
Name and Title Within Firm: |
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b. |
Project Assignment: |
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b. |
Project Assignment: |
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c. |
Name and Address Of Office In Which Individual Identified In 7a Resides: |
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Name and Address Of Office In Which Individual Identified In 7a Resides: |
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MBE |
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MBE |
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WBE |
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WBE |
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SDOVBE |
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SDOVBE |
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VBE |
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VBE |
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d. |
Years Experience: With This Firm: |
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With Other Firms: |
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d. |
Years Experience: With This Firm: |
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With Other Firms: |
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e. |
Education: Degree(s) /Year/Specialization |
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e. |
Education: Degree(s) /Year/Specialization |
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f. |
Active Registration: Year First Registered/Discipline/Mass Registration Number |
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f. |
Active Registration: Year First Registered/Discipline/Mass Registration Number: |
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g. |
Current Work Assignments and Availability For This Project: |
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Current Work Assignments and Availability For This Project |
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h. |
Other Experience and Qualification Relevant To The Proposed Project: (Identify Firm By |
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Other Experience and Qualification Relevant To The Proposed Project: (Identify Firm By |
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Which Employed, If Not Current Firm): |
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Which Employed , If Not Current Firm): |
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Updated July 2016
Current and Relevant Work By Prime Applicant Or
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) |
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Services (Include Reference To Areas |
Number. Include Name Of Contact Person |
Date (Actual |
Construction |
Fee For Work For |
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Of Experience Listed In DSB |
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Or Estimated) |
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Costs(Actual, Or |
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Which Firm Was |
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Advertisement) |
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Estimated If Not |
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Responsible. |
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Completed) |
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(1) |
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(2)
(3)
(4)
(5)
Updated July 2016
8b. List Current and Relevant Work By
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) |
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Services (Include Reference To |
(Include Name Of Contact Person) |
Date (Actual |
Construction |
Fee for Work for |
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Areas Of Experience Listed In DSB |
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Or Estimated) |
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Costs (Actual, Or |
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Which Firm Was |
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Advertisement) |
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Estimated If Not |
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Responsible |
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Completed) |
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(1) |
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(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: |
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# of Active Projects: |
Total Construction Cost (In Thousands) |
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of Active Projects (excluding studies): |
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Role |
Phases |
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Construction Costs |
Completion Date |
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Awarding Authority (Include Contact Name and |
(In Thousands) |
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P, C, JV |
St., Sch., D.D., |
Project Name, Location and |
(Actual or Estimated) |
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Phone Number) |
(Actual, or |
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C.D.,A.C. * |
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(R)Renovation or (N)New |
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Estimated if Not |
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1. |
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2. |
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3. |
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4.
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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
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. |
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d. |
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b. |
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e. |
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c. |
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f. |
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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. |
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d. |
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b. |
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e. |
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c. |
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f. |
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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. |
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d. |
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b. |
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e. |
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c. |
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f. |
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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 ____________ |
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(Signature) |
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The following forms MUST be attached to only ONE (ORIGINAL Copy) application: 1. SDO Certification required for MBE/WBE Firms; 2.
Updated July 2016
DSB
Commonwealth of Massachusetts
Designer Selection Board
Project:
Applicant Designer:
The
Signature of
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
Updated July 2016 |
DSB |