Form DS-4053 Mentor-Protege Program Application

U.S. Department of State

MENTOR-PROTÉGÉ PROGRAM APPLICATION

Approved OMB 1405-0161
Expires: 05-31-2011
Estimated Burden: 21 Hours
See Page 3

A signed mentor-protégé application for each mentor-protégé relationship should be submitted to the Office of Small
Business Development (OSDBU) for approval.

1.

Mentor Firm Information. Provide the following:

Name of Firm

Contact Name

Position Title

Address

Telephone Number

Fax

2.

E-mail

Homepage

Protégé Firm Information. Provide the following:

Name of Firm

Contact Name

Position Title

Address

Telephone Number

Fax

E-mail

Homepage

The remainder of the information requested may be provided in narrative form.

3.

Eligibility. Provide a statement certifying that the company is currently eligible pursuant to the following
criteria below:
A Small Business concern that meets the definition at FAR 19.001, based on its primary NAICS code is eligible to
be a protégé firm. SBA Regulations/FAR Provision: FAR 19.001; 13 CFR Part 121; CFR 124.1002.
.
The Protégé firm's primary NAICS code is
The Protégé represents, for general statistical purposes that it is a (check one):
Small

Small Disadvantaged

8(a) Business concern as defined above.

The Protégé represents that it
Is
Is Not a HUBZone small business concern listed, on the
date (mm-dd-yyyy) of this representation, on the List of Qualified HUBZone small business concerns maintained
by the Small Business Administration.
The Protégé represents that it

Is

Is Not a Woman-owned small business concern.

The Protégé represents that it

Is

Is Not a Veteran-owned small business concern.

The Protégé represents that it
business concern.

Is

Is Not a Service disabled veteran-owned small

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4.

Developmental Assistance Program. Describe the development program for the protégé firm
specifying type of assistance planned. Types of developmental assistance a mentor firm can provide to a protégé
firm may include:
Management guidance relating to Financial management
Organizational management
Overall business management/planning and
Business development
Technical assistance
Rent-free use of facilities and/or equipment
Property
Temporary assignment of personnel to the protégé firm for the purpose of training
Loans; and
Any other types of mutually beneficial assistance

5.

Milestones. Define milestones for providing the identified developmental assistance.

6.

Metrics. In addition to the developmental assistance plan, provide factors to assess the protégé firm's
developmental progress under the program.

7.

Subcontract Awards to Protégé(s). The number and total dollar amount of subcontract awards
made to the identified protégé firm(s) during the two preceding fiscal years (if any).

Total Subcontract Awards to Protégé(s)
Number

Dollar Amount

FYFY8.

Estimate of Cost. Provide an estimate of the total cost of the developmental assistance.

9.

Program Participation Term. State the period of time over which the developmental assistance will
be performed.

10. Potential Subcontracts. Provide the anticipated dollar value and type of subcontracts that may be
awarded to the protégé firm consistent with the extent and nature of mentor firm's business, and the period of
time over which they may be awarded.

11. Mentor Termination Procedures. Describe the procedures for the mentor firm to notify the protégé
firm in writing at least 30 days in advance of the mentor firm's intent to voluntarily withdraw its participation in the
program.

12. Protégé Termination From the Program. Describe the procedures for a protégé firm to notify the
mentor firm in writing at least 30 days in advance of the protégé firm's intent to voluntarily terminate the
mentor-protégé agreement.

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13. Other Termination Procedures. Describe the procedures for the mentor firm to terminate the mentorprotégé agreement for cause which provide:
The protégé firm shall be furnished a written notice of the proposed termination, stating the specific reasons
for such action, at least 30 days in advance of the effective date of such proposed termination.
The protégé firm shall have 30 days to respond to such notice of proposed termination,and may rebut any
finding believed to be erroneous and offer a remedial program.
Upon prompt consideration of the protégé firm's response, the mentor firm shall either withdraw the notice of
proposed termination and continue the protégé firm's participation, or issue the notice of termination.
The mentor firm shall submit a plan for accomplishing work should the agreement be terminated.

14. Signed Agreement. Mentors and Protégés are asked to sign and date the agreement. The parties shall
state they agree to comply with the obligations in all clauses and provisions governing the program. Titles of the
individuals should also be included as shown in the following example:

Mentor

Protégé

Printed Name

Printed Name

Signature

Signature

Title

Title

Date (mm-dd-yyyy)

Date (mm-dd-yyyy)

PRIVACY ACT STATEMENT
Public reporting for this collection of information is estimated to be 21 hours per response. This includes time required
for searching existing data sources, gathering the necessary documentation, providing the information and/or
documents required, and reviewing the final collection. In accordance with 5 CFR 1320 5(b), you are not required to
respond to the collection of information unless this form display a currently valid OMB control number.

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