Clear Form
Michigan Department
of Transportation
1242 (06/17)
Page 1 of 5
CONSULTANT PREQUALIFICATION APPLICATION
NOTE: This completed form must be included with all submittals; including requests for initial
prequalification, renewals, and requests for new classifications.
LEGAL ENTITY NAME
DATE
FED. I.D. NO.
ASSUMED NAME
FISCAL YEAR (MONTH/DAY)
CHECK IF APPLICABLE OVERHEAD TIER
Safe Harbor Overhead Rate
CHECK ONE
Minority Owned Business
Woman Owned Business
Overhead Rate Compilation
CPA FAR Compliant Overhead Audit
Minority Woman Owned Business
CERTIFICATION AFFIDAVIT
The undersigned affirms they have read and understand all statements and supporting documentation submitted in this
application package, and that everything is true and correct and includes all material information necessary to identify
and explain the operations of ____________________________________________. Any misrepresentation will be
grounds for revoking prequalification and for initiating action under federal or state laws concerning false statements. The
undersigns also affirms that this company is in compliance with all applicable Michigan laws and regulations.
I understand that by signing below, I have/will use the E-Verify system to verify that new employees are legally
present and authorized to work in the United States. I agree to supply/receive information electronically and
agree to utilize MDOT’s current digital signature software as the legal equivalent of my hand-written signature
on all required transactions.
PRINT OR TYPE NAME, SAME AS SIGNATURE BELOW
TITLE
AUTHORIZED SIGNATURE
DATE
9088551
MDOT 1242 (06/17)
Page 2 of 5
IS THE COMPANY SEEKING PREQUALIFICATION A SUBSIDIARY OF ANOTHER CORPORATION? If yes, supply name of corporation
and other information below. Yes
No
NAME OF CORPORATION
ADDRESS
CITY
STATE
ZIP CODE
STATE IN WHICH INCORPORATED
Indicate whether the Vendor is a parent corporation and list the name and address of each subsidiary company.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Indicate whether the Vendor has affiliates and the name and address of each such related company.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Indicate whether any of the related companies listed are engaged in similar or related business as that of the above named
company.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Indicate other businesses in which any officer, member, owner or partner, etc. is actively engaged.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
MDOT 1242 (06/17)
Page 3 of 5
Indicate whether the company, its parent, subsidiary, or any owner, stockholder, officer, partner, or employee of the company
has been suspended or debarred from doing business by any State or the Federal government?
Yes
No
If yes, please explain:
CONTACT INFORMATION FOR PREQUALIFICATION AND
PRIMARY AUTHORIZED SIGNER
PLEASE LIST THE NAME AND ADDRESS OF YOUR FIRM'S CONTACT PERSON FOR WHICH ALL PREQUALIFICATION
INFORMATION AND AWARDED CONTRACTS WILL BE SENT FOR SIGNATURE.
NAME
TITLE
ADDRESS
TYPE
CITY
STATE
ZIP CODE
PHONE (Include Area Code)
COUNTY OF
Main/HQ
E-MAIL ADDRESS
FAX (Include Area Code)
STATE
Billing Address
Michigan Branch
Mail Address
Other _____________________
MDOT 1242 (06/17)
PERSONS AUTHORIZED TO EXECUTE CONTRACTS
Page 4 of 5
All partners must sign contracts, unless a power of attorney modifying this is supplied. In case of a corporation, only those
signatures listed below will be accepted. The following persons are duly authorized to sign contracts and related documents
on behalf of: ___________________________________________________________________________________________
NOTE: In addition, CORPORATIONS will complete the Certificate of Secretary listing those persons authorized to sign
contracts.
NAME (Print or type same as
corresponding signature
AUTHORIZED SIGNATURE
DATE
PRIMARY CONTRACT
SIGNER
(Check One)
CERTIFICATE OF SECRETARY **
The undersigned, being the duly elected secretary of (Company Name)____________________________________
a (State)__________________________________ corporation, hereby certifies that the following resolution was duly
adopted by the Board of Directors of said corporation at a meeting held on (Date) __________, and that this resolution
is in full force and effect.
“RESOLVED, that the above listed persons are hereby authorized to sign, for __________________________________
any contract with the State of Michigan or other governmental entity.”
SIGNATURE OF SECRETARY
DATE
**NOTE:Only CORPORATIONS are required to complete the Certificate of Secretary listed above.
9088551
MDOT 1242 (06/17)
STAFF EDUCATION AND EXPERIENCE REPORT
Page 5 of 5
NOTE: Complete for each key staff member listed on key staff form for each prequalification classification requested. Please note that this form is just
template and not all portions of the form are fillable. You may choose to replace the template with your own resume format.
EMPLOYEE NAME
TITLE
ROLE ON THIS SERVICE
NUMBER YEARS OF EXPERIENCE
_______ years with company ______ years with other consultant/vendors
COMPANY NAME
EDUCATION (Degree, year, school (include city and state of school))
LICENSES AND REGISTRATIONS (Type, year, state, number)
GENERAL EXPERIENCE AND QUALIFICATIONS (for prequalification only)
SPECIFIC EXPERIENCE
YEARS
(enter as mo/yr to mo/yr)
PROJECT I.D.
(Please provide MDOT contract
number if applicable)
ROLE AND DESCRIPTION OF SERVICE
.