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Owners Project Manager Application Form  March 2017
 1.Project Name/Location for Which Firm is Filing:

  

1a. MSBA Project Number:
 2a.Respondent, Firm (Or Joint-Venture) - Name And  Address Of Primary Office To Perform The Work:  2b.Name And Address Of Other Participating Offices Of The Prime Applicant, If Different From Item  3a Above:2c.



Date Present And Predecessor Firms Were Established:



2d.Name And Address Of Parent Company, If Any:2e.Federal ID #:2f.Name of Proposed Project Director:3.Personnel From Prime Firm Included In Question #2 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):
Admin. PersonnelCost EstimatorsOtherArchitectsElectrical Engrs.Acoustical Engrs.Environmental Engrs.Civil Engrs.Licensed Site Profs.Code SpecialistsMechanical Engrs.Construction InspectorsTotal4.Has this Joint-Venture previously worked together?( Yes( No
5.List ONLY Those Prime and Sub-Consultant Personnel identified as Key personnel in the Response to Request for Services.  This Information Should Be Presented Below In The Form Of An Organizational Chart modified to fit the firms proposed management approach.  Include Name of Firm And Name Of The Person:
6.Brief Resume for Key Personnel ONLY as indicated in the Request for Services.    Resumes Should Be Consistent With The Persons Listed On The Organizational Chart In Question # 5.  Additional Sheets Should Be Provided Only As Required For The Number Of Key Personnel And They Must Be In The Format Provided.  By Including A Firm As A Subconsultant, 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 6a Resides:c.Name And Address Of Office In Which Individual Identified In 6a Resides:d.Years Experience:  With This Firm:With Other Firms:d.Years Experience:  With This Firm:With Other Firms:e.Education:  Degree(s) /Year/Specializatione.Education:  Degree(s) /Year/Specialization

f.Date of MCPPO Certification:
f.Date of MCPPO Certification:
g.Applicable Registrations and Certifications :  g.Applicable Registrations and Certifications:  



h.Current Work Assignments And Availability For This Project (availability should be identified as a percentage: eg: As of 5/30, 50% available):





h.Current Work Assignments And Availability For This Project (availability should be identified as a percentage: eg: As of 5/30, 50% available): 






i.Other Experience And Qualifications Relevant To The Proposed Project: (Identify OPM Firm By Which Employed, If Not Current Firm. Please distinguish between OPM work and any design work performed by the firm.):i.Other Experience And Qualifications Relevant To The Proposed Project: (Identify OPM Firm By Which Employed, If Not Current Firm. Please distinguish between OPM work and any design work performed by the firm.):










7aPast Performance:  List all Completed Projects, in excess of $1.5 million, for which the Prime Applicant has performed, or has entered into a contract to perform Owners Project Management Services for all Public Agencies within the Commonwealth within the past 10 years.a.Project Name And Location
Project Directorb.	Brief Description Of Project And Services (Include Reference To Areas Of  Similar Experience)c.	Project Dollar Valued.  Completion  Date (Actual Or Estimate)e. On Time (Yes Or No)f. Original Construction Contract Valueg.	Change Ordersh.  Number of Accidents and Safety Violationsi. Dollar Value of any Safety finesj. Number And Outcome Of Legal Actions(1)






(2)






(3)






(4)





(5)






7b.
(cont)Past Performance:  Provide the following information for those completed Projects listed above in 7a for which the Prime Applicant has performed, or has entered into a contract to perform Owners Project Management Services for all Public Agencies within the Commonwealth within the past 10 years.a.Project Name And Location
Project Directorb.	 Original Project Budgetc.	Final Project Budgetd.  If different, provide reason(s) for variancee. Original Project Completione. Actual Project Completion
On Time (Yes or No)f. If different, provide reason(s) for variance.(1)






(2)






(3)






(4)





(5)









8.Capacity:  Identify all current/ongoing Work by Prime Applicant, Joint-Venture Members or Sub-consultants.  Identify project participants and highlight any work involving the project participants identified in the response.
Project Name And Location
Project Directorb.	Brief Description Of Project And Services (Include Reference To Areas Of  Similar Experience)c. Original Project Budgetd. Current Project Budgetd.  Project Completion  Date e. Current forecast
completion date
   On Time (Yes Or No)f. Original Construction Contract Valueg. Number and dollar value of Change Ordersh.  Number and dollar value of claims1.


2.


3.


4.


5.


6.


7.


8.








9.
References:  Provide the following information for completed and current Projects listed above in 7 and 8 for which the Prime Applicant has performed, or has entered into a contract to perform Owners Project Management Services for all Public Agencies within the Commonwealth within the past 10 years.a.Project Name And Location
Project DirectorClients Name, Address and Phone Number.  Include Name of Contact PersonProject Name And Location
Project DirectorClients Name, Address and Phone Number.  Include Name of Contact PersonProject Name And Location
Project DirectorClients Name, Address and Phone Number.  Include Name of Contact Person1)






5)9)2)






6)10)3)






7)11)4)





8) 12)






9. Use This Space To Provide Any Additional Information Or Description Of Resources Supporting The Qualifications Of Your Firm And That Of Your Sub-consultants.  If Needed, Up To Three, Double-Sided 8  X 11 Supplementary Sheets Will Be Accepted.  APPLICANTS ARE REQUIRED TO RESPOND SPECIFICALLY IN THIS SECTION TO THE AREAS OF EXPERIENCE REQUESTED.







10.

I hereby certify that the undersigned is an Authorized Signatory of Firm and is a Principal or Officer of Firm.  The information contained in this application is true, accurate and sworn to by the undersigned under the pains and penalties of perjury. Submitted By (Signature)
__________________________________________________
Printed Name And Title
 _______________________________
Date
____________ 































Attachment D
Required Certifications (To be developed by the Owner)









PAGE  


Revised March 2017	Page  PAGE 15 of  NUMPAGES 22

01/00		DSB 2000 Application  Page  PAGE 1


CITY/TOWN/DISTRICT

Schematic Design/Design
Development


Construction
Phase

Name of Project Representative
(Title must appear as Project Representative)



Sub-consultant


Prime Consultant(s)
Project Director and Project Manager