Architect, Engineer, & Related Services Supplement to Statement of Qualifications
Nebraska Department of Transportation, Project Development Division, Attn: Agreements Engineer, 1500 Hwy 2, PO Box 94759, Lincoln NE 68509-4759	DEPT. USE ONLY
Contractor No.:
Purpose: This form must be submitted by firms responding to the Nebraska Department of Transportation’s (NDOT) “Request for Professional Consultant Services” (RFP). Instructions: Numbers below correspond to numbers on the form. Please type all information. 1. Submitting firm name and address. a. Indicate whether this form is being submitted on behalf of a parent firm or a branch office. (Branch office sub-missions must list only personnel in, and experience of, that office.) b. Firm’s Federal Identification Number, or Social Security Number in absence of Federal I.D. No. 2. Work category(s) number(s) and name(s), identified in the NDOT’s RFP, the firm is submitting on. 3. Address of the submitting office, if different than No. 1. 4. Name, title, telephone and FAX number of two principals from the submitting firm who may be contacted by the state. Listed principals must be empowered to speak for the firm on policy and contractual matters. 5. Total number of employees, by discipline, in the submitting office. While some personnel may be qualified in several disciplines, each person should be counted only once in accordance with his or her primary function. Include clerical personnel as “Administrative.” Write in any additional disciplines on the blank lines provided, along with the number of employees in that discipline.	6. Name, office address and certificate information of key personnel of the firm holding a certificate of registration granted by the Nebraska State Board of Examiners for Professional Engineers and Architects, the Nebraska Board of Landscape Architectural Examiners, or the Nebraska State Board of Examiners for Land Surveyors. Such individuals must have full authority to make all final engineering, architectural or surveying decisions on behalf of the firm with respect to the designated work categories. 7. List not more than ten projects which demonstrate the firm’s competence in the relevant work categories. The most recent projects completed for the Nebraska Department of Transportation are preferred. Information must include: a. Name and location of the project. b. Brief description of the firm’s responsibilities on the project. c. Name and address of the owner of the project. d. Estimated or actual project completion date. e. Total construction cost of the completed project, (or where no construction was involved, the approximate cost of your work) and that portion of the cost of the project your firm was/is responsible for. 8. Brief resumes of key personnel expected to participate in the advertised projects. Each resume must include: a. Individual’s name and title. b. Project assignment that person will be expected to fulfill.	c. Years of relevant experience with this firm and other firms. d. Highest academic degree achieved, the year, and the discipline covered (if more than one highest degree such as two PhD’s, list both). e. Active registration as an architect, engineer, surveyor, etc., the field of registration, year such registration was acquired and the state(s) granting such registration. f. Experience, training and other qualifications which reflect the individual’s potential contributions to the advertised projects. Include such data as: familiarity with NDOT procedures and engineering techniques, similar types of work performed in the past, and management abilities. Please limit synopsis of experience to relevant work categories. 9. Brief narrative discussion indicating the primary reasons your firm is especially qualified to complete the advertised projects. Information provided might include such data as specialized equipment and computer software, awards or recognition received by the firm or individuals in the relevant work categories, or special approaches or concepts developed by the firm in the relevant work categories. 10. Name of any firms you intend to sub-contract a portion of the project work to and work they will perform. 11. This completed form must be signed and dated by principal of the firm.
1. FIRM NAME AND ADDRESS:	1a. SUBMITTAL IS FOR:	Parent Company Branch
1b. FEDERAL I.D. NO. OR SOCIAL SECURITY NO.:
2. WORK CATEGORY NUMBER(S) AND NAME(S):
3. ADDRESS OF SUBMITTING OFFICE: (If different from Item 1)	4. NAME, TITLE, TELEPHONE AND FAX NUMBER OF PRINCIPALS TO CONTACT:
5. PERSONNEL BY DISCIPLINE: (Submitting Office)
Administrative	Electrical Engineers	Mechanical Engineers
Architects	Engr. Technicians/Aides	Planners: Urban/Regional
Biologists	Environ. Scientist	Sanitary Engineers
Chemical Engineers	Estimators	Social Scientists
Civil Engineers	Geologists	Soils Engineers
Construction Inspectors	Hydrologists	Structural Engineers
Drafters	Instrument/Rod/Chain Persons, etc.	Surveyors, RLS
Ecologists	Interior Designers	Systems Engineers
Economists	Landscape Architects	Transportation Engineers	Total Personnel in Submitting Office

Name of Firm:

6. KEY PERSONNEL:	CERTIFICATE:
NAME AND ADDRESS	NUMBER	DATE	TYPE
7. WORK BY FIRM, OR NEW EMPLOYEES OF THE FIRM, WHICH BEST ILLUSTRATES CURRENT QUALIFICATIONS RELEVANT TO THIS CATEGORY OF WORK.
a. Project Name and Location	b. Nature of Firm’s Responsibility	c. Owner’s Name and Address	d. Completion Date (actual or estimated	e. Estimated Cost (in thousands)
Entire Project	Work for which firm was/is responsible
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)

Name of Firm:

8. BRIEF RESUME OF KEY PERSONNEL: (Duplicate this sheet, if necessary)
a. NAME AND TITLE:	a. NAME AND TITLE:	a. NAME AND TITLE:
b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:
c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:
With this Firm	With Other Firms	With this Firm	With Other Firms	With this Firm	With Other Firms
d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:
e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State
f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.
a. NAME AND TITLE:	a. NAME AND TITLE:	a. NAME AND TITLE:
b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:
c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:
With this Firm	With Other Firms	With this Firm	With Other Firms	With this Firm	With Other Firms
d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:
e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State
f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.

Name of Firm:

8. BRIEF RESUME OF KEY PERSONNEL: (Duplicate this sheet, if necessary)
a. NAME AND TITLE:	a. NAME AND TITLE:	a. NAME AND TITLE:
b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:
c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:
With this Firm	With Other Firms	With this Firm	With Other Firms	With this Firm	With Other Firms
d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:
e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State
f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.
a. NAME AND TITLE:	a. NAME AND TITLE:	a. NAME AND TITLE:
b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:
c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:
With this Firm	With Other Firms	With this Firm	With Other Firms	With this Firm	With Other Firms
d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:
e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State
f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.

Name of Firm:

8. BRIEF RESUME OF KEY PERSONNEL: (Duplicate this sheet, if necessary)
a. NAME AND TITLE:	a. NAME AND TITLE:	a. NAME AND TITLE:
b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:
c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:
With this Firm	With Other Firms	With this Firm	With Other Firms	With this Firm	With Other Firms
d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:
e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State
f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.
a. NAME AND TITLE:	a. NAME AND TITLE:	a. NAME AND TITLE:
b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:	b. PROBABLE WORK ASSIGNMENT:
c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:	c. YEARS EXPERIENCE:
With this Firm	With Other Firms	With this Firm	With Other Firms	With this Firm	With Other Firms
d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:	d. EDUCATION: Degree(s)/Year/Specialization:
e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State	e. ACTIVE REGISTRATION: Year First Registered/Discipline/State
f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.	f. OTHER EXPERIENCE AND QUALIFICATIONS RELEVANT TO THE PROPOSED PROJECT.

Name of Firm:

9. USE THIS SPACE TO PROVIDE ANY ADDITIONAL INFORMATION OR DESCRIPTION OF RESOURCES SUPPORTING YOUR FIRM’S QUALIFICATIONS FOR THE PROPOSED PROJECT:
10. SUBCONSULTANTS AND THEIR WORK:
11. THE FOREGOING IS A STATEMENT OF FACTS. (Signature)	TYPED NAME AND TITLE:	DATE: