Architect, Engineer, & Related Services Annual Certification Form
Nebraska Department of Transportation Project Development Division Attn: Agreements Engineer 1500 Hwy 2 PO Box 94759 Lincoln NE 68509-4759 NDOT.PDAnnualCertification@nebraska.gov	DEPT. USE ONLY
Contractor No.:
Purpose: The policy of the State of Nebraska in procuring architectural, engineering and related professional services, is to consider for such work only firms which are certified to complete such services. This form is provided for that purpose. Interested firms must complete and submit this form to the Nebraska Department of Transportation at the email/address above. Instructions: Standard Work Categories: Please indicate the type(s) of work your firm is interested in doing in Nebraska by placing a checkmark in the appropriate box or boxes. See Standard Work Categories manual for minimum qualifications for each category. https://dot.nebraska.gov/media/6081/ ndor_std_wrk_categories.pdf Numbers below correspond to numbers contained on the form. 1. Firm Name and Address of Primary Office.	a. Indicate whether this form is being submitted on behalf of a parent firm or a branch office. (Branch office sub-missions must list only personnel in, and experience of, that office.) b. Firm’s Federal Identification Number, or Social Security Number in absence of Federal I.D. No. 2. Date the firm was established under the name shown in item 1. 3. Type of ownership, or legal structure, of the firm (sole proprietor, partnership, corporation, joint venture, etc.) a. Certified Disadvantaged Business Enterprise. 4. Branches or subsidiaries of larger or parent companies, or conglomerates, should insert the name and address of the highest tier owner. Note: If the present firm is the successor to, or outgrowth of, one or more predecessor firms, show the name(s) of former entity(ties) and the year(s) of their original establishment.	5. Name, title, email address, telephone, and FAX number of two Primary Contacts. 6. Office locations and total number of personnel for headquarters and branch offices. 7. Total number of employees, by discipline, in the submitting office. While some personnel may be qualified in several disciplines, each person should be counted only once in accordance with his or her primary function. Include clerical personnel as “administrative.” Write in any additional disciplines and the number of people for each in the spaces provided. 8. This completed form must be signed and dated by a principal of the firm. Note: The Agreements Engineer will determine the firm’s eligibility for certification and acknowledge by email writing within 30 days certification of the firm or the reasons for denial.
Standard Work Categories
Professional Services 100 Corridor Studies 101 Environmental Studies A. NEPA Studies Requires additional submittal. requirements located at: http://dot.nebraska.gov/media/6077/cert-instruc-nepa-studies.pdf B. Other Environmental Studies 102 Transportation Planning 103 Traffic Operation Studies 104 Traffic Operation Design 105 Highway Design - Major A. Rural B. Urban 106 Highway Design - Minor A. Rural B. Urban	107 Bridge Design A. Major B. Minor 108 Railroad Design 109 Construction Inspection A. Bridge B. Roadway C. Traffic Control Devices D. Railroad Construction and Improvement Projects 110 Building Design and Inspection 111 Electrical and Mechanical Design 112 Railroad Planning 113 Intelligent Transportation Systems (ITS)	Support Services 200 Aerial Photography 201 Aerial Photogrammetry 202 Engineering Surveying 203 Geodetic Surveying 204 Land Surveying 205 Materials Testing 206 Pavement Design A. New Construction B. Resurfacing 207 Geological Studies 208 Bridge A. NBIS Bridge Inspections B. Load Rating 209 Hydraulic and Hydrologic Studies 210 ROW Design A. Land Ownership Research B. Right of Way Plans C. Legal Description and/or Plats 211 Public Involvement 212 Value Engineering Other Categories Not Listed:
300
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304
1. Firm Name and Address:	1a. Submittal is for: Parent Company Branch
1b. Federal I.D. No. or Social Security No.:

NDOT Form 497, November 2019

Name of Firm:

2. Year Present Firm Was Established:	3. Type of Ownership:	3a. Certified Disadvantaged Business Enterprise: Yes No
4. Name of Parent Company and Address: (If not in 1. above)
5. Primary Contacts: (1) Name Title Email Address Telephone Fax 2) Name Title Email Address Telephone Fax
6. Other Locations: City State Number of Personnel City State Number of Personnel
7. Personnel by Discipline: (Primary Office)
Administrative	Electrical Engineers	Mechanical Engineers	Transportation Engineers
Architects	Engineering Technicians/Aides	Planners: Urban/Regional
Biologists	Environmental Scientists	Public Involvement Specialist
Chemical Engineers	Estimators	Sanitary Engineers
Civil Engineers	Geologists	Social Scientists
Construction Inspectors	Hydrologists	Soils Engineer
Drafters	Instrument/Rod/Chain Persons	Structural Engineers
Ecologists	Interior Designers	Surveyors, RLS	Total Personnel in Primary Office
Economists	Landscape Architect	Systems Engineers
8. The foregoing is a statement of facts. (Signature)	Typed Name:	Title:	Date: