SAME Membership Profile Questionnaire

APPENDIX A

SAME Membership Profile Questionnaire

We realize the following questionnaire is not as applicable to design and consultant firms as it is to construction firms. However, please respond to the items with your expertise in mind whether it is construction, design, consulting, or supply.

If you have suggestions to improve this form for next year's update, please let us know. Thank you.

SAME Sustaining Membership Profile

(Voluntary Agreement to Participate)

Firm Name:______

Address:______

Phone: (_____)______FAX: (_____)______

E-Mail Address: ______

Person to Contact: Alternate:

Name: ______Name: ______

Address: ______Address: ______

______

E-Mail: ___ _ _ E-Mail: ___ _

Phone Bus.: (_____)______Phone Bus.: (_____) ____ Fax: (_____)______Fax: (_____)______

Cell: (_____)______Cell: ( )______

Home: (_____)______Home: (_____)______

Type of Firm:

A&E (_____) Contractor (_____) Supplier (_____)

Geographic Work Areas:

1) Washington, DC (_____) 4) Other Areas

2) Northern VA (_____)

3) Suburban MD (_____)

SAME Membership Profile Questionnaire

Company Name: ______

GSA Schedules Relevant to Emergency Preparedness:

Schedule Contract #

1)______2)______3)______4)______5)______

To complete the section below, see the following page for classifications of contractor emergency preparedness capabilities.

Business Class: ______

Emergency Response Capability

Experience: ______

Support:______

Specialties: ______

______

Sample entry of entries that will be found in Appendix B, Washington Post Member Capabilities.

Michael Baker Corporation

3601 Eisenhower Avenue

Alexandria, VA 22304

http://:www.mbakercorp.com

POC: Joe LaVoie

(703) 960-8800

fax (703) 960-9125

GSA Schedule: GSA Corporate Schedule, Contract #: GS-00F-0032M (Engineering, Environmental, GIS, IT, Energy Management, MOBIS Schedules)

U.S. Department of Transportation (DOT) Contract #: DTTS59-01-D-00750

(GIS, Mapping and Related Services) Applies to any Federal, state, or local government

Business Class: Architect-Engineering, Planning, Environmental, Mapping & Surveying

Emergency Response Capability: Experience: E, F, L, T Support: 1, 2, 3, 5, 13

Specialties: Water Resources, Transportation, Mapping, Program Management, Civil Engineering

APPENDIX A

SAME Membership Profile Questionnaire

Contractor Emergency Response Capabilities

Emergency Capability Codes: The codes listed below were extracted from the SAME Directory and were originally developed by the SAME Readiness Committee. They are used to identify the types of services that contractors may be able to provide subsequent to a disaster or local emergency.