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Mentor-Protégé Program Application and Participation Agreement
Company Name:
Company Website:
Company Address:
City:
State:
Zip:
Company contact participating in this program:
Contact Phone:
Contact Email:
Are you applying to be a Mentor or a Protégé? Mentor
  Protégé
If your business concern has been in operation for three years or longer, please provide the annual gross revenue for the last three fiscal years and any subsidiaries and affiliates:
Fiscal Year Annual Gross Revenue
2008 $
2007 $
2006 $
State why you want to participate in the Mentor-Protégé program:
Specify 3-5 goals you wish to achieve by participating in this program:
Business start date: Number of full-time employees:
  Number of part-time employees:
Specialty:
Name of Primary Insurance Company:
Agent: Phone number:
Type of coverage: Amount of coverage: $
Name of Secondary Insurance Company:
Agent: Phone number:
Type of coverage: Amount of coverage: $
Name of Bonding Company:
Agent: Phone number:
Single: Aggregate:
Legal Structure of Business: Corporation LLC Partnership Sole Proprietorship
Other (please specify):
If you are applying to be a Mentor, please indicate your industry segment:
As a mentor, do you have a preference for the type of Protégé (industry segment) that you wish to mentor? Yes No
If yes, please indicate the industry segment:
As a Mentor: Please check the categories where you provide assistance
As a Protégé: Please check the categories where you need assistance
Accounting Records Preparation & Maintenance Banking Services
Blueprint Reading Bonding & Insurance
Business Plan Competitive Marketplace Overhead
Construction Equipment & Materials Cost Accounting
Implementation and Action Plans Job Cost & Work In Progress
Marketing/Business Development
      Organization Structure		 Obtaining Permits & Subcontracts
Payrolls (Federal, State Fringe Benefits) Personnel Management
Post Award Bid Assessment of Successful
      & Unsuccessful Bidders		 Preparing & Negotiating Change Orders,
      Job Budgets, Trade payment Breakdowns
Project Planning & Scheduling Prompt Payment Procedures
Reading & Interpreting Plans & Specifications Records & Contract Management
Scheduling & Purchasing Take-offs
Troubleshooting & Avoidance Delay  
Proof of Certification (Protégé)
Protégé’s please include with your Application and Participation Agreement a copy of your M/WBE Certification.