Architectural, Engineering and Professional Design and Consulting Services - Purchasing Department

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Business Name of applicant

Street, PO BOX

City. State, ZIP

*Telephone

Fax Number

Company Website

Tax I.D

S.S. Number

DUNS Number

Applicant Contact Person

Contact Person's Title

Email Address

Vendor ID, Addr seq No

1. Business Organizations

Corporations

Corporation

State of Incorporation

Year

Subsidiary / Division of:

Headquarters Address

DUNS Number

Parent to

List Subsidiaries and Divisions

Partnership

General Limited

State and County where partnership was filed :

Date of Organization

Individual Proprietorship

Date of Organization

Joint Venture

Date of Organization

Years your organization has been in business as a Professional Design or Consulting firm :

Years your organization has been in business under its present name :

List other or former names under which your organization has operated :

2. Licensing Information

List company or principal registration/license numbers, locations and the states to which they apply :

3. Classification

Type of Business: (check only ONE)

A Small Business B Large Business E Labor Surplus Area- Small Business S Labor Surplus Area – Large Business H Non-Profit Organization I Foreign-Based

Ownership:

F Women- Owned (WBE) J Handicapped / ADA (DBE) C Minority / Disadvantaged (MBE)

(minority/disadvantaged subcategories)

African American Puerto Rican Native American (includes Indians, Aleut & Native Hawiian) Hispanic American Asian/Indian American (includes India, Pakistan, Bangladesh) Asian/Pacific American (includes Asia, Pacific Islands, etc.)

Ownership Certification: (attach copy of certification letter) This information is optional and is not required – it may be supplied at the discretion of the applicant.

MMBDC (Michigan Minority Business Development Council) NAWBO (National Association of Women Business Owners) MWBC (Michigan Women’s Business Council) Other :

4. Experience

Summary of Experience: Provide a summary list of noteworthy experience relating to your firms professional abilities, expertise, and capabilities. Information should be current for the past five (5) years only, and should only be considered for the primary firm listed (not for parent companies, partnerships, or similar). Incorrect or insufficient information may result in the Prequalification Statement being dismissed or voided and removed from the current list of vendors.

Total # of Completed Projects:

Total # of Current Projects:

# of Completed projects valued less than $625,000 in Construction Cost:

# of Current projects valued less than $625,000 in Construction Cost:

# of Completed projects valued $625,000 to $2,000,000 in Construction Cost:

# of Current projects valued $625,000 to $2,000,000 in Construction Cost:

# of Completed projects Greater than $2,000,000 in Construction Cost:

# of Current projects Greater than $2,000,000 in Construction Cost:

# of Completed Higher Education Projects:

# of Completed LEED Projects:

Certified

Silver

Gold/Platinum

# of Current LEED Projects:

Certified

Silver

Gold/Platinum

# of Projects Completed with Eastern Michigan University (Total):

Past 5 Years: 2009

2008

2007

2006

2005

Project / Work Type Breakdown: In the last 5 years, what percentage of your total workload was for the following:

Higher Education

K-12

Commercial

Residential

Industrial

Municipal

Other

Higher Education Subcategories (total to 100%):

Hospital/Healthcare

Science/Research

Classroom

Office

Performing Arts

Residence Hall

Library

Sports Facility

Food Service

Support Facility

Parking / Traffic

Apartment

Public Safety

Security

Specific Projects:Provide a Project Resume of noteworthy projects relating to your firms professional abilities, expertise, and capabilities. Information should be current for the past five (5) years only, and should only be considered for the primary firm listed (not for parent companies, partnerships, or similar). Incorrect or insufficient information may result in the Prequalification Statement being dismissed or voided and removed from the current list of vendors.

Project Name:

Client Name:

Project Cost:

Project Type: Renovation

Brief Project Description:

Project Location:

Client Contact:

Year of Completion:

New Construction:

Other:

Project Name:

Client Name:

Project Cost:

Project Type: Renovation

Brief Project Description:

Project Location:

Client Contact:

Year of Completion:

New Construction:

Other:

Project Name:

Client Name:

Project Cost:

Project Type: Renovation

Brief Project Description:

Project Location:

Client Contact:

Year of Completion:

New Construction:

Other:

Project Specialization Examples:Provide no more than five (5) examples of projects highlighting the Primary, Secondary, and Specialization services of your firm (refer to page 7 for description). Each project example shall consist of a single page and include all critical information necessary to describe the project name, location, client, scope, cost, contact information, and general description.