REQUEST FOR PROPOSAL COVER SHEETMichigan Department

of Transportation 5100D (11/17)

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PROJECT INFORMATION

MDOT PROJECT MANAGER JOB NUMBER CONTROL SECTION (CS)

RFP DUE DATE DBE % GOAL (If applicable) MDOT REQUISITION NUMBER

PRIME CONSULTANT INFORMATION

PRIME FIRM NAME

ADDRESS

CITY STATE ZIP CODE

PHONE NO. FAX NO.

CONTACT PERSON EMAIL

INDIVIDUAL OR SOLE PROPRIETORSHIP CORPORATION PARTNERSHIP

LICENSED TO OPERATE IN THE STATE OF MICHIGAN? (License required to contract with MDOT.)

YES NO

CERTIFIED AS A DBE IN MICHIGAN?

YES NO

DBE % OF SERVICE GOAL:

LIST APPLICABLE SERVICE PREQUALIFICATIONS AS LISTED IN RFP, (P) PRIMARY OR (S) SECONDARY, AND (DBE) IF DBE CERTIFIED:

eg. Roads and Streets (P) (DBE)

CONFLICT OF INTEREST STATEMENT

(Consultant) certifies that it has read and understands the following:

The CONSULTANT and its Affiliates agree not to have any public or private interest, and shall not acquire directly or indirectly any such interest in connection with the project, that would conflict or appear to conflict in any manner with the performance of the services under this Contract. "Affiliate" means a corporate entity linked in the CONSULTANT through common ownership. The CONSULTANT and its Affiliates agree not to provide any services to a construction contractor or any entity that may have an adversarial interest in a project for which it has provided services to the DEPARTMENT. The CONSULTANT and its Affiliates agree to disclosed to the DEPARTMENT all other interests that the prime or sub consultants have or contemplate having during each phase of the project. The phases of the project include, but are not limited to, planning, scoping, early preliminary engineering, design, and construction. In all situations, the Department will decide if a conflict of interest exists. If the CONSULTANT and its Affiliates choose to retain the interest constituting the conflict, the DEPARTMENT may terminate the Contract for cause in accordance with the provisions stated in this Contract.

Certification for Subject Project. Based on the foregoing, the Consultant certifies that no conflict exists with the subject project for it, its Affiliates, and any sub-consultants. Disclose of Conflict with Subject Project. Based on the foregoing, the Consultant certifies that the following conflict exists with the subject project for it, its Affiliates, and/or any sub-consultants.

MDOT 5100D (11/17)Page 2 of 2

available and have sufficient time to provide the services as outlined in the Request for Proposal for the life of the above project. The following is an estimate of the average number of hours per week that the Consultant anticipates the key staff identified in this proposal will devote to the project throughout the life of the project. For key staff performing tasks that will not be performed consistently throughout the life of the project (i.e. surveying, geotechnical, etc.), the hours listed below are the anticipated average number of hours that will be devoted while these tasks are performed.

CERTIFICATION OF AVAILABILITY OF KEY PERSONNEL It is the consultant’s responsibility to notify MDOT of any changes to the availability of key staff listed on this form throughout the entire

contracting process. Notification of Changes to Key Personnel may be noted on form 5100G.

(Consultant) certifies that the following key personnel are

NAME TITLE

AVERAGE NUMBER OF HOURS PER

WEEK ON PROJECT (LEAVE BLANK FOR

AS-NEEDED SERVICE)

PHONE NUMBER

PRIME CONSULTANT SIGNATURE (SIGNER MUST HAVE CONTRACTING AUTHORITY) DATE