Form DS-4053 Department of State Mentor Protégé Program Application

U.S. Department of State

MENTOR-PROTÉGÉ PROGRAM APPLICATION

Approved OMB 1405-0161
Expires: xx-xx-xxxx
Estimated Burden: 12 Hours *

A signed mentor-protégé application for each mentor-protégé relationship should be submitted to the Office of Small Business Development (OSDBU)
for approval.

1. Mentor Firm Information
Contact Name

Name of Firm

Position Title

Address

Telephone Number

Fax Number

E-mail

Homepage

Contact Name

Position Title

2. Protégé Firm Information
Name of Firm

Address

Telephone Number

Fax Number

E-mail

Homepage

The remainder of the information requested may be provided in narrative form.

3. Eligibility
Provide a statement certifying that the company is currently eligible pursuant to the following criteria below:
1. Must be a small business, veteran-owned small business, service-disabled veteran-owned small business, HUBZone, small socially
and economically disadvantaged business, and women-owned small business (SBA Regulations: 13 CFR 124 and 126).
2. Must be small as determined by the requirements of the specific NAICS code designated by the Mentor and for supplies or services the
.
Protégé may provide to the Mentor under a subcontract with the Mentor.
3. The Protégé's NAICS code is
4. The Protégé firm (check one):

is

is not eligible for U.S. Government contracts.

5a. Please check the appropriate box that the mentor firm represents:
Small Business

Large Business

5b. Please check the appropriate boxes that the protégé firm represents:
Small Business

Woman-Owned Small Business

Small Disadvantaged Business

Veteran-Owned Small Business

8(a)

Service Disabled Veteran-Owned Small Business

Hubzone Small Business
List the date (mm-dd-yyyy)
by the Small Business Administration.

.

of this representation, on the List of Qualified HubZone small business maintained

4. Developmental Assistance Program
Describe the development program for the protégé firm specifying type of assistance planned. Types of developmental assistance a mentor firm can
provide to a protégé firm may include:

•

•
•
•

Management guidance relating to -

•
•
•

Financial management
Organizational management

Overall business management/planning and business development
Technical assistance
Rent-free use of facilities and/or equipment
Property

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 12 hours per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do
not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and/or recommendations for reducing it, please send them to: OSDBU, SA-6, L500 Washington, D.C. 20522
DS-4053
xx-xxxx

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4. Developmental Assistance Program (continued)

•
•
•

Temporary assignment of personnel to the protégé firm for the purpose of training
Loans; and
Any other types of mutually beneficial assistance

Annually after initial agreement, please provide an accomplishment report describing the following:
Summary of the value of the Mentor-Protégé agreement:

•
•
•
•
•

Supporting the Department of State mission and objectives
Increasing the protégé's ability to participate in DOS, Federal, and/or commercial contracts and subcontracts
Improving small business subcontracting opportunities in industry categories where eligible protégés or other small business categories are
not dominant in the mentor's vendor base
Progress in meeting your agreed upon objectives
Recommendation for continuation of the agreement for the previous FY

Please attach Mentor Protégé Agreement.

5. Milestones
Define milestones for providing the identified developmental assistance.

6. Metrics
In addition to the developmental assistance plan, provide factors to assess the protégé firm's developmental progress under the program.

7. Subcontract Awards to Protégé(s)
The number and total dollar amount of subcontract awards made to the identified protégé firm(s) during the two preceding fiscal years (if any).
Total Subcontract Awards to Protégé(s)
Number

Dollar Amount

FYFY-

8. Estimate of Cost
Provide an estimate of the total cost of the developmental assistance.

9. Program Participation Term
State the period of time over which the developmental assistance will be performed.

10. Potential Subcontracts
Provide the anticipated dollar value and type of subcontracts that may be awarded to the protégé firm consistent with the extent and nature of mentor
firm's business, and the period of time over which they may be awarded.

11. Mentor Termination Procedures
Describe the procedures for the mentor firm to notify the protégé firm in writing at least 30 days in advance of the mentor firm's intent to voluntarily
withdraw its participation in the program.

12. Protégé Termination From the Program
Describe the procedures for a protégé firm to notify the mentor firm in writing at least 30 days in advance of the protégé firm's intent to voluntarily
terminate the mentor-protégé agreement.

13. Other Termination Procedures
Describe the procedures for the mentor firm to terminate the mentor-protégé agreement for cause which provide:

•

The protégé firm shall be furnished a written notice of the proposed termination, stating the specific reasons for such action, at least 30 days
in advance of the effective date of such proposed termination.

•

The protégé firm shall have 30 days to respond to such notice of proposed termination,and may rebut any finding believed to be erroneous
and offer a remedial program.

•

Upon prompt consideration of the protégé firm's response, the mentor firm shall either withdraw the notice of proposed termination and
continue the protégé firm's participation, or issue the notice of termination.

•

The mentor shall submit a plan for accomplishing work to the OSDBU-Mentor Protégé Program Manager should the work be terminated.

14. Signed Agreement
Mentors and Protégés are asked to sign and date the agreement. The parties shall state they agree to comply with the obligations in all clauses and
provisions governing the program. Titles of the individuals should also be included.
Mentor

Protégé

Mentor Name

Mentor Title

Protégé Name

Protégé Title

Mentor Signature

Date (mm-dd-yyyy)

Protégé Signature

Date (mm-dd-yyyy)

DS-4053

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