Form DOT F 4500 DOT F 4500 The Regional Center Intake Form

U.S. Department of Transportation Small Business Transportation Resource Center Regional Field Office Intake Form

OMB Control Number: 2105-0554 Expiration Date: 01/31/2012 Form DOT F 4500

Public Burden Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2105-0554. Public reporting for this collection of information is estimated to be approximately 90 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Room W57-463, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

PART A – CLIENT CONTACT INFORMATION

Full Legal Name of Business:

Full Street Address of Primary Business Location:

Website:

Last Name:

First Name:

Title:

Email Address:

Area Code & Phone No:

Fax:

PART B – BUSINESS INFORMATION

Dun & Bradstreet (DUNS) #:

Registered in Central Contractor Registration (ccr.gov): □ Yes □ No

Type of Business Formation:

Primary Trade or Services Provided: NAICS Code(s)

Type of Contractor: □ Prime □ Subcontractor

Length of Time in Continuous Operation:

No of Employees (Last 3 Years): Year 1: Year 2: Year 3:

Revenue (Last 3 Years): Year 1: Year 2: Year 3:

Certification(s) – Check All That Apply: □ DBE States: _________________ □ 8(a) □ SDB □ MBE Agency: □ VOB □ SDVOB □ WBE Agency: □ HubZone □ Women-Owned Small Business □ Non-Certified

Answer the Following Questions if the business is interested in DOT’s Financial Assistance or Bonding Programs

Does the business currently hold a surety bond? □ Yes □ No If not, has the business or a principal in the business held a surety bond in the past?: □ Yes □ No

Has the business or a principal in the business filed for bankruptcy in the past?: □ Yes □ No

Has a principal in the business had a prior felony conviction?: □ Yes □ No

PART C – TYPE OF ASSISTANCE REQUESTED

Type of Assistance – Check All That Apply: □ Technical Assistance (accounting, planning, contract review, marketing, bidding and estimating, project management, financing, ect.) □ Financial Assistance (DOT Short Term Lending Program or other financial assistance) □ Bonding (DOT Bonding Education Program or other bonding assistance) Please provide a brief narrative of the type of assistance the business is seeking (be specific):

PART D – TO BE COMPLETED BY THE SBTRC

Region:

Date:

Client No:

Rev. 4/12 OPI: Office of Small and Disadvantaged Business Utilization

General Instructions

Purpose of Form

Use form Regional Field Office Intake Form, OMB Control Number 2105-0554, to request the assistance of the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Utilization (OSDBU), Regional Field Office Small Business Transportation Center (SBTRC) that serves your region in order to be better prepared to compete for or perform on contracts in the transportation industry.

Who is Eligible for assistance?

To be eligible, you must be a small or small and disadvantaged business able to provide goods or services to a Transportation-Related contract. "Transportation-Related" means that the Scope of Work pertains to a transportation project for the maintenance, rehabilitation, restructuring, improvement, or revitalization of any of the nation's modes of transportation; and that the transportation project is funded in whole, or in part, with funds from the U.S. Department of Transportation.

How do I Obtain More Information?

You can contact the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Business Utilization for further information:

Email. [email protected] .

Voice. 1-800-532-1169 or 202-366-1930. A long-distance charge to callers located outside of the local calling area will apply when calling the 202-366-1930 number.

For direct assistance, please contact the (SBTRC) that serves your state. A complete list of SBTRCs, the states that each region serves, and their contact information is located at http://www.osdbu.dot.gov/regional/index.cfm.

How do I Obtain Assistance?

Direct assistance will be delivered by the SBTRC that serves your state. The SBTRC will assist you to complete the Regional Field Office Intake Form, supply further submission instructions, and develop a plan to deliver the required assistance. A complete list of SBTRCs, the states that each region serves, and their contact information is located at http://www.osdbu.dot.gov/regional/index.cfm.

Specific Instructions

All entries on the form are voluntary. Print or type all entries on the Form, OMB Control Number 2105-0554. The form is an electronically fillable form. We strongly suggest applicants utilize the electronically fillable form to complete the form entries. Illegible forms will delay processing time. Follow the instructions for each line to expedite processing and to avoid unnecessary requests for additional information.

Line 1. Full Legal Name of Business. Enter the full legal name of the business.

Line 2. Full Street Address of Primary Business Location. Enter the full mailing address of the business’s primary physical location.

Line 3. Website. If applicable, enter the business’s website address.

Line 4. Last Name. Enter the last name of the individual who will be the SBTRC’s primary contact with the business.

Line 5. First Name. Enter the first name of the individual who will be the SBTRC’s primary contact with the business.

Line 6. Title. Enter the title of the individual who will be the SBTRC’s primary contact with the business.

Line 7. Email Address. Enter the email address where the business may best be contacted.

Line 8. Area Code & Phone No. Enter the business or mobile phone number where the business may best be contacted.

Line 9. Fax. Enter the fax number where the business may best be contacted.

Line 10. Dun & Bradstreet (DUNS) #. Enter the business’s DUNS# exactly as it appears on the document provided by Dun & Bradstreet. If the business not registered, it can register online at http://fedgov.dnb.com/webform .

Line 11. Registered in Central Contractor Registration (ccr.gov). Check “Yes” to indicate that the business: 1) has a DUNS #; and 2) has registered the DUNS# at www.ccr.gov. Instructions may be found in on-line help at www.ccr.gov.

Line 12. Type of Business Formation. Enter the legal formation of the business (Sole Proprietorship, Partnership, Corporation, LLC, ect.).

Line 13. Primary Trade or Services Provided. Enter a description of the goods or services provided by the business. Include applicable NAICS Code(s).

Line 14. Type of Contractor. Check the appropriate box to indicate whether the business is primarily a prime contractor or a subcontractor.

Line 15. Length of Time in Continuous Operation. Enter the length of time that the business has been actively providing goods and/or services.

Line 16. No of Employees (Last 3 Years). Enter the number of employees over the past 3 years. If the business has not been in operation for 3 years, enter “N/A’ in the years where the business was not in operation.

Line 17. Revenue (Last 3 Years). Enter the business’s revenue over the past 3 years. If the business has not been in operation for 3 years, enter “N/A’ in the years where the business was not in operation.

Line 18. Certifications. Check all of the certifications held by the business. Please note that certification is nit required to obtain assistance.

Line 19. Does the business currently hold a surety bond?. The business should provide a response to this question if interested in bonding or financial assistance. Check the box to indicate whether the business currently holds a surety bond, and, if not, check the box to indicate whether the business or a principal in the business has held a surety bond in the past.

Line 20. Has the business or a principal in the business filed for bankruptcy in the past?. The business should provide a response to this question if interested in bonding or financial assistance. Check the box to indicate whether the business or a principal in the business has filed for bankruptcy in the past. A “Yes” answer does not make a business ineligible for services provided by the SBTRC.

Line 21. Has a principal in the business had a prior felony conviction?. The business should provide a response to this question if interested in bonding or financial assistance. Check the box to indicate whether a principal in the business has been convicted of a felony in the past. A “Yes” answer does not make a business ineligible for services provided by the SBTRC.

Line 22. Type of Assistance. Check the type of assistance that the business is seeking from the SBTRC. Provide a brief description of the specific assistance requested, such as: 1) technical assistance in a specific area, such as accounting, planning, contract review, marketing, bidding and estimating, project management, or financing; 2) financial assistance in the form of the DOT Short Term lending program, or other financial assistance; and 3) bonding assistance in the form of the DOT Bonding Education Program or other bonding assistance offered by DOT or other organizations.

Line 23. Region. Enter the name of the SBTRC Region. Reserved for entry by the SBTRC.

Line 24. Date. Enter the date of completion and submission of the Regional Field Office Intake Form to the SBTRC. Reserved for entry by the SBTRC.

Line 25. Client No. The client number assigned to the business. Reserved for entry by the SBTRC.

Privacy Act Statement

This notice is provided pursuant to the Privacy Act, 5 U.S.C. 552a(e)(3): The information on this form is solicited under the authority of Title 49 U.S.C. 332(b)(4)(7). The principal purpose for which the information is to be used is to assist the SBTRC to consult with the business and formulate an assistance plan. Contact information will be used to communicate with the business to formulate service plans, inform businesses of new programs and services offered by DOT, and to notify the business of potential networking and business opportunities. Other possible routine uses of information are published in the Federal Register at 65 F.R. 19476 (April 11, 2000) under “Prefatory Statement of General Routine Uses.” Furnishing the information requested on this form is voluntary, but failure to provide all or part of the information may delay the formulation of an assistance plan and delivery of the required services.

Rev. 4/12 OPI: Office of Small and Disadvantaged Business Utilization