Form GSA 3695 GSA 3695 GSA Mentor Protege Program Application

GSA MENTOR-PROTÉGÉ PROGRAM APPLICATION

OMB Control Number: 3090-0286
Expiration Date: XX/XX/20XX

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The
OMB control number for this collection is 3090-0286. We estimate that it will take 3 hours to read the instructions, gather the facts, and answer the questions.
Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S.
General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
A signed Mentor-Protégé Application, to include the Mentor-Protege Agreement, for each Mentor-Protégé relationship must be submitted as part of this application to the
Office of Small Business Utilization (OSBU) for approval. Additional information may be included in narrative form on a separate document. This will also be submitted as an
attachment to the application. Application must be electronically submitted via e-mail to [email protected]

1. Mentor Firm Information (See 519.7010(a)) Provide the following:
a. NAME OF FIRM
b. CONTACT NAME

c. POSITION TITLE

d. TELEPHONE NUMBER

e. ADDRESS

f. E-MAIL ADDRESS

g. HOME PAGE

2. Mentor Eligibility Information
Is not a small business (See 519.7006(a)).

a.

Is a small business (See 519.7006(a)).

b.

Is currently performing under at least one active, approved subcontract plan
(Small Business is exempt) (See 519.7009(b)(1)).

c.

Is eligible, as of the date of this application, for award of federal contracts (See 519.7006(b)).

d.

e.

Do you have any other GSA Proposed Protégé arrangements?
If yes, explain:

Yes

No

Mentor and Protégé agree to comply with 519.7015, Reports.

have not verified the eligibility status of the
have
f. Eligibility Statement: The mentor affirms that they
protégé as per Federal Acquisition Regulation (FAR) 19.7 and/or any additional SBA regulations.
g. Data on all current GSA contracts (See 519.7009(b)(3)) and subcontracts (See 519.7009(b)(3)) to include:
h.

Yes
No
Do you have a sustainability plan in place?
GSA MENTOR ELIGIBILITY

(All participating mentors are required to have an active GSA contracting vehicle to participate in the GSA Mentor-Protege Program.)

Contract Number

Contract Type

Schedule

Point of Contact

When applicable, indicate the technical program effort(s) (Program Title), name of GSA Project Manager and/or
Contracting Officer’s Representative (including contact information)(See 519.7009(b)(3)).

3. Protégé Firm Information (See 519.7010(a)) Provide the following:
a. NAME OF FIRM
b. CONTACT NAME

c. POSITION TITLE

d. TELEPHONE NUMBER

e. ADDRESS

f. E-MAIL ADDRESS

GENERAL SERVICES ADMINISTRATION

g. HOMEPAGE

GSA 3695 (REV. XX/20XX)

4. Eligibility of Protégé (519.7010(b)). Provide a statement certifying that the company is
currently eligible pursuant to the following criteria:
(a) Protege must be at least one (1) of the following: Small Business, Veteran-Owned Small Business,
Service-Disabled Veteran-Owned Small Business, HUB Zone Small Business, Small Socially and
Economically Disadvantaged Business, and Women-Owned Small Business (See SBA Regulations: 13 CFR
124, 125 and 126 and GSAM 519.7007(a)(1)). The Protégé represents that it is (check all that apply):
Small Business

Small Disadvantaged Business (SBD) / 8(a)

Veteran-Owned Small Business (VOSB)

Service Disabled Veteran-Owned Small Business
(SDVOSB)

HUB Zone

Women-Owned Small Business (WOSB)

(b) Must be small as determined by the requirements of the specific NAICS code. (See 519.7007(a)(2)).
Protégé’s primary NAICS code
(c) The Protégé represents that it
contracts (See 519.7007(d)(3)).

is eligible, as of the date of this application, for award for federal

have not
have
(d) Eligibility Statement: The Protege affirms that they
verified their eligibility
status with the Mentor as per Federal Acquisition Regulation (FAR) 19.7 and/or any additional SBA
regulations.
Yes
No
(e) Does the Protege currently have any active GSA Contracting Vehicles?
If yes, please list:
(f) Is the Protege currently involved in any other active Mentor-Protege relationships?
If yes, please list:

Yes

No

5. Developmental Assistance Plan Information (See 519.7010(c)). Please explain the
primary items in your development assistance plan for the execution of this agreement
between you and your team. Please provide the developmental assistance your firm will
provide in bullet form. (Examples of developmental assistance may include: training,
management guidance, financial management, organizational management, sustainability
training, overall business management/planning and/or business development.) Information
on the proposed types of developmental assistance. For each proposed Mentor-Protégé
relationship include information on the company's ability to provide developmental assistance
to the identified protégé firm and how that assistance will potentially increase subcontracting
opportunities for the protégé firm, including subcontracting opportunities in industry categories
where these entities are not dominant in the company's current subcontractor base (See
519.7009(b)(5)).

GSA 3695 (REV. XX/20XX) Page 2 of 4

6. Program Participation Term. State the period of time over which the developmental
assistance will be performed (See 519.7010(g)). Maximum Participation term is 4 years.
One (1) Year

Two (2) Years

Three (3) Years

Four (4) Years

7. Mentor Termination Procedures. Describe the procedures for the mentor firm to notify
the protégé firm in writing at 30 days in advance of the mentor firm's intent to voluntarily
withdraw its participation in the Program, or to terminate the Agreement (See 519.7010(h)).

8. Protégé Termination From the Program. Describe the procedures for a protégé firm to
notify the mentor firm in writing at 30 days in advance of the protégé firm's intent to voluntarily
terminate the Mentor-Protégé agreement (See 519.7010(i)).

9. Other Termination Procedures (See 519.7010(j)). Describe below the procedures for the
mentor firm to terminate the Mentor-Protégé agreement for cause.

GSA 3695 (REV. XX/20XX) Page 3 of 4

10. Signed Agreement. Mentor Firm and Protégés are asked to sign and date this agreement. The
parties shall state they agree to comply with the obligations in all clauses and provisions governing the
program.

Mentor Firm

Protégé

Printed Name

Printed Name

Signature

Signature

Title

Title

Date

Date

GSA 3695 (REV. XX/20XX) Page 4 of 4