Ga Uniform Application Form – Fill Out and Use This PDF

DISADVANTAGED BUSINESS ENTERPRISE PROGRAM

49 C.F.R. PART 26

GEORGIA Uniform Certification Application

Georgia Department of Transportation

Equal Opportunity Division

One Georgia Center

600 West Peachtree Street, N.W., 7th Floor

ATLANTA, GEORGIA 30308

Phone: (404) 631-1972

ROADMAP FOR APPLICANTS

Should I apply?

OIs your firm at least 51%-owned by a socially and economically disadvantaged individual(s) who also controls the firm?

OIs the disadvantaged owner a U.S. citizen or lawfully admitted permanent resident of the U.S.?

OIs your firm a small business that meets the Small Business Administration’s (SBA’s) size standard and does not exceed $20.41 million in gross annual receipts?

OIs your firm organized as a for-profit business?

If you answered “Yes” to all of the questions above, you may be eligible to participate in the GEORGIA DOT DBE program.

Is there an easier way to apply?

If you are currently certified by the SBA as an 8(a) and/or SDB firm, you may be eligible for a streamlined certification application process. Under this process, the certifying agency to which you are applying will accept your current SBA application package in lieu of requiring you to fill out and submit this form. NOTE: You must still meet the requirements for the DBE program, including undergoing an on-site review.

Be sure to attach all of the required documents listed in the Documents Checklist at the end of this form with your completed application.

Where can I find more information?

OGA. DOT – http://www.dot.ga.gov/doingbusiness/dbePrograms/Pages/default.aspx

OU.S. DOT – http://osdbuweb.dot.gov/business/dbe/index.html (this site provides useful links to the rules and regulations governing the DBE program, questions and answers, and other pertinent information)

ONAICS codes search – http:www.naics.com/search.htm

OSBA Size Standards http://www.sba.gov/size/indextableofsize.html

O49 CFR Part 26 (the rules and regulations governing the DBE program) http://www.fhwa.dot.gov/hep/49cfr.26.htm

Under Sec. 26.107 of 49 CFR Part 26, dated February 2, 1999, if at any time, the Department or a recipient has reason to believe that any person or firm has willfully and knowingly provided incorrect information or made false statements, the Department may initiate suspension or debarment proceedings against the person or firm under 49 CFR Part 29, take enforcement action under 49 CFR Part 31, Program Fraud and Civil Remedies, and/or refer the matter to the Department of Justice for criminal prosecution under 18 U.S.C. 1001, which prohibits false statements in Federal programs.

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INSTRUCTIONS FOR COMPLETING THE DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM

GEORGIA UNIFORM CERTIFICATION APPLICATION

NOTE: If you require additional space for any question in this application, please attach additional sheets or copies as needed,

taking care to indicate on each attached sheet/copy the section and number of this application to which it refers.

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DBE UNIFORM CERTIFICATION APPLICATION SUPPORTING DOCUMENTS CHECKLIST

In order to complete your application for DBE certification, you must attach copies of all of the following

documents as they apply to you and your firm.

All Applicants

Work experience resumes (that include places of ownership/employment with corresponding dates), for all owners and officers of your firm

Personal Financial Statement (form available with this application)

Personal tax returns for the past three years, if applicable, for each owner claiming disadvantaged status (complete signed copies)

Your firms tax returns (gross receipts) and all related schedules for the past three years (complete signed copies)

Documented proof of contributions used to acquire ownership for each owner (e.g. both sides of cancelled check or statement on company letterhead)

Your firm’s signed loan agreements, security agreements, and bonding forms

Descriptions of all real estate (including office/storage space, etc.) owned/leased by your firm and documented proof of ownership/signed leases

List of equipment leased and signed lease agreements if applicable

List of construction equipment and/or vehicles owned and titles/proof of ownership

Documented proof of any transfers of assets to/from your firm and/or to/from any of its owners over the past two years if applicable

Year-end balance sheets and income statements for the past three years (or life of firm, if less than three years); a new business must provide a current balance sheet

All relevant licenses, license renewal forms, permits, and haul authority forms

DBE and SBA 8(a) or SDB certifications denials, and/or decertifications, if applicable

Bank authorization and signatory cards

Schedule of salaries (or other compensation or remuneration) paid to all officers, managers, owners, and/or directors of the firm

Trust agreements held by any owner claiming disadvantaged status, if any

Partnership or Joint Venture

Original and any amended Partnership or Joint Venture Agreements

Corporation or LLC

Official Articles of Incorporation (signed by the state official)

Both sides of all corporate stock certificates and your firms stock transfer ledger

Shareholders’ Agreement

Minutes of all stockholders and board of directors meetings

Corporate by-laws and any amendments

Corporate bank resolution and bank signature cards

Official certificate of Formation and Operating Agreement with any amendments (for LLCs)

Trucking Company

Documented proof of ownership of the company

Insurance agreements for each truck owned or operated by your firm

Title(s) and registration certificate(s) for each truck owned or operated by your firm

List of U.S. DOT numbers for each truck owned or operated by your firm

Regular Dealer

Proof of warehouse ownership or lease

List of product lines carried

List distribution equipment owned and/ or leased

Note: The specific state UCP to which you are applying may have additional required documents that you must also supply with your application. Contact the appropriate certifying agency to which you are applying to find out if more is required.

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GEORGIA UNIFORM CERTIFICATION PROGRAM

Section 1: CERTIFICATION INFORMATION

A.	Prior/Other Certifications
Is your firm currently certified for  DBE		Name of certifying agency:
any of the following programs?
(If Yes, check appropriate box(es))
		Has your firm’s state UCP conducted an on-site visit?

Yes, on ___/___/___ State: ___________  No

8(a)  STOP! If you checked either the 8(a) or SDB box, you may not

	have to complete this application. Ask your state UCP about the
 SDB
	streamlined application process under the SBA-DOT MOU.

B.Prior/Other Applications and Privileges

Has your firm (under any name) or any of its owners, Board of Directors, officers or management personnel, ever withdrawn an application for any of the programs listed above, or ever been denied certification, decertified, or debarred or suspended or otherwise had bidding privileges denied or restricted by any state or local agency, or Federal entity?

Yes, on ___/___/___  No

If Yes, identify State and name of state, local, or Federal agency and explain the nature of the action:

Section 2: GENERAL INFORMATION

A.Contact Information

(1)	Contact person and Title:						(2) Legal name of firm:
(3)	Phone #:		(4) Other Phone #:							(5) Fax #:
(6)	E-mail:				(7) Website (if have one):
(8)	Street address of firm (No P.O. Box):			City:			County/Parish:			State:	Zip:
(9)	Mailing address of firm (if different):			City:			County/Parish:			State:	Zip:
B.	Business Profile
(1)	Describe the primary activities of your firm:							(2) Federal Tax ID (if any):
(3)	This firm was established on ____/____/____						(4) I/We have owned this firm since: ____/____/____
(5)	Method of acquisition (check all that apply):
 Started new business		 Bought existing business					 Inherited business			 Secured concession

Merger or consolidation  Other (explain) _____________________________

(6) Is your firm “for profit”?  Yes  No  STOP! If your firm is NOT for-profit, then you do NOT qualify for this program and do NOT need to fill out this application.

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(7)Type of firm (check all that apply):

Sole Proprietorship

Partnership

Corporation

Limited Liability Partnership

Limited Liability Corporation

Joint Venture

Other, Describe: ________________________________________________

(8)Has your firm ever existed under different ownership, a different type of ownership, or a different name?

Yes  No

If Yes, explain:

(9) Number of employees: Full-time __________ Part-time __________ Total __________

(10)Specify the gross receipts of the firm for the last 3 years: Year _______ Total receipts $ ______________

Year _______ Total receipts $ ______________

Year _______ Total receipts $ ______________

C.Relationships with Other Businesses

(1)Is your firm co-located at any of its business locations, or does it share a telephone number, P.O. Box, office

space, yard, warehouse, facilities, equipment, or office staff, with any other business, organization, or entity?  Yes  No

If Yes, identify: Other Firm’s name: _______________________________________________

Explain nature of shared facilities:

(2)	At present, or at any time in the	(a) been a subsidiary of any other firm?	 Yes	 No
past, has your firm:		(b) consisted of a partnership in which one or more of the partners are other
		firms?	 Yes  No
		(c) owned any percentage of any other firm?	 Yes  No
		(d) had any subsidiaries?	 Yes	 No
(3)	Has any other firm had an ownership interest in your firm at present or at any time in the past?		 Yes	 No

(4)If you answered “Yes” to any of the questions in (2)(a)-(d) and/or (3), identify the following for each (attach extra sheets, if needed):

Name

Address

Type of Business

1.

2.

3.

D.Immediate Family Member Businesses

Do any of your immediate family members own or manage another company?  Yes  No If Yes, then list (attach extra sheets, if needed):

Name Relationship Company Type of Business Own or Manage?

1.

2.

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Section 3: OWNERSHIP

Identify all individuals or holding companies with any ownership interest in your firm, providing the information requested below (If more than one owner, attach separate sheets for each additional owner):

A.Background Information

(1)	Name:		(2) Title:					(3) Home Phone #:
(4)	Home Address (street and number):					City:			State:	Zip:
(5)	Gender:  Male  Female			(6) Ethnic group membership (Check all that apply):
				 Black			 Hispanic		 Native American
(7)	U.S. Citizen:  Yes	 No
				 Asian Pacific			 Subcontinent Asian
(8)	Lawfully Admitted Permanent Resident:
				 Other (specify) _________________________________
 Yes  No
B.	Ownership Interest
(1)	Number of years as owner:					(2) Initial investment to			Type	Dollar Value
						acquire ownership			Cash	$
(3)	Percentage owned:
						interest in firm:			Real Estate	$
(4)	Familial relationship to other owners:
									Equipment $
									Other	$
(5)	Shares of Stock:	Number	Percentage		Class		Date acquired		Method Acquired
(6)	Does this owner perform a management or supervisory function for any other business?  Yes									 No

If Yes, identify: Name of Business: __________________________________ Function/Title: _______________________________

(7) Does this owner own or work for any other firm(s) that has a relationship with this firm (e.g., ownership interest,

shared office space, financial investments, equipment, leases, personnel sharing, etc.)?  Yes  No

If Yes, identify: Name of Business: _______________________________ Function/Title: _____________________________

Nature of Business Relationship:

C.Disadvantaged Status – NOTE: Complete this section only for each owner applying for DBE qualification (i.e. for each owner claiming to be socially and economically disadvantaged)

(1) What is the Personal Net Worth (PNW) of the owner(s) applying for DBE qualification? (Use and attach the Personal Financial Statement form at the end of this application; attach additional sheets if more than one owner is applying)

(2)Has any trust been created for the benefit of this disadvantaged owner(s)?  Yes  No If Yes, explain (attach additional sheets if needed):

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Business: ________________________________ Function: ___________________________

(12)Do any of the persons listed in (1) through (10) above own or work for any other firm(s) that has a relationship

with this firm (e.g., ownership interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)?

 Yes  No

If Yes, identify for each: Firm Name: _______________________________ Person: _____________________________

Nature of Business Relationship:

C.Indicate your firm’s inventory in the following categories (attach additional sheets if needed):

(1)Equipment

	Type of Equipment	Make/Model		Current Value		Owned or Leased?
(a)
(b)
(c)
(2)	Vehicles
	Type of Vehicle	Make/Model		Current Value		Owned or Leased?
(a)
(b)
(c)
(3)	Office Space
	Street Address		Owned or Leased?		Current Value of Property or Lease
(a)
(b)
(4)	Storage Space
	Street Address		Owned or Leased?		Current Value of Property or Lease
(a)
(b)

D.Does your firm rely on any other firm for management functions or employee payroll?  Yes  No

If Yes, explain:

E.Financial Information

(1) Banking Information:

(a) Name of bank: _________________________________		(b) Phone No: (		) __________________________
(c) Address of bank: _______________________________		City: ______________ State: _____ Zip: __________
(2)	Bonding Information: If you have bonding capacity, identify:		(a) Binder No: ________________________
(b)	Name of agent/broker ________________________________		(c) Phone No: (		) ______________________

(d) Address of agent/broker: ____________________________ City: ______________ State: _____ Zip: _______

(e) Bonding limit: Aggregate limit $ ______________________ Project limit $ _____________________

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F.Identify all sources, amounts, and purposes of money loaned to your firm, including the names of any persons or firms securing the loan, if other than the listed owner:

Name of Source	Address of Source	Name of Person	Original	Current	Purpose of Loan
		Securing the Loan	Amount	Balance
1.
2.
3.

G.List all contributions or transfers of assets to/from your firm and to/from any of its owners over the past two years (attach additional sheets if needed):

Contribution/Asset	Dollar Value	From Whom	To Whom	Relationship	Date of
		Transferred	Transferred		Transfer
1.
2.
3.

H.List current licenses/permits held by any owner and/or employee of your firm (e.g. contractor, engineer, architect, etc.)(attach additional sheets if needed):

Name of License/Permit Holder	Type of License/Permit	Expiration	License Number
		Date	and State

1.

2.

3.

I.List the three largest contracts completed by your firm in the past three years, if any:

Name of	Name/Location of	Type of Work Performed	Dollar Value of
Owner/Contractor	Project		Contract
1.
2.
3.

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J.List the three largest active jobs on which your firm is currently working:

Name of Prime	Location of	Type of Work	Project	Anticipated	Dollar
Contractor and Project	Project		Start Date	Completion	Value of
Number				Date	Contract
1.
2.
3.

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AFFIDAVIT OF CERTIFICATION

This form must be signed and notarized for each owner upon which disadvantaged status is relied.

A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION

IS SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL,

INITIATION OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR

ENTITY MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES

AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW.

I _________________________ (full name printed), swear or affirm under penalty of law that I am

__________________ (title) of applicant firm ________________________ (firm name) and that I have read and

understood all of the questions in this application and that all of the foregoing information and statements submitted in this application and its attachments and supporting documents are true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information. The responses include all material information necessary to fully and accurately identify and explain the operations, capabilities and pertinent history of the named firm as well as the ownership, control, and affiliations thereof.

I recognize that the information submitted in this application is for the purpose of inducing certification approval by a government agency. I understand that a government agency may, by means it deems appropriate, determine the accuracy and truth of the statements in the application, and I authorize such agency to contact any entity named in the application, and the named firm’s bonding companies, banking institutions, credit agencies, contractors, clients, and other certifying agencies for the purpose of verifying the information supplied and determining the named firm’s eligibility.

I agree to submit to government audit, examination and review of books, records, documents and files, in whatever form they exist, of the named firm and its affiliates, inspection of its places(s) of business and equipment, and to permit interviews of its principals, agents, and employees. I understand that refusal to permit such inquiries shall be grounds for denial of certification.

If awarded a contract or subcontract, I agree to promptly and directly provide the prime contractor, if any, and the Department, recipient agency, or federal funding agency on an ongoing basis, current, complete and accurate information regarding (1) work performed on the project; (2) payments; and (3) proposed changes, if any, to the foregoing arrangements.

I agree to provide written notice to the recipient agency or Unified Certification Program (UCP) of any material change in the information contained in the original application within 30 calendar days of such change (e.g., ownership, address, telephone number, etc.).

I acknowledge and agree that any misrepresentations in this application or in records pertaining to a contract or subcontract will be grounds for terminating any contract or subcontract which may be awarded; denial or revocation of certification; suspension and debarment; and for initiating action under federal and/or state law concerning false statement, fraud or other applicable offenses.

I certify that I am a socially and economically disadvantaged individual who is an owner of the above-referenced firm seeking certification as a Disadvantaged Business Enterprise (DBE). In support of my application, I certify that I am a member of one or more of the following groups, and that I have held myself out as a member of the group(s) (circle all that apply):

Female	Black American	Hispanic American	Native American
Asian- Pacific American		Subcontinent Asian American
Other (specify) ____________________________.

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I certify that I am socially disadvantaged because I have been subjected to racial or ethnic prejudice or cultural bias, or have suffered the effects of discrimination, because of my identity as a member of one or more of the groups identified above, without regard to my individual qualities.

I further certify that my personal net worth does not exceed $750,000, and that I am economically disadvantaged because my ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same or similar line of business who are not socially and economically disadvantaged.

I declare under penalty of perjury that the information provided in this application and supporting documents is true and correct.

Executed on ______________(Date)

Signature ________________________________

(DBE Applicant)

NOTARY CERTIFICATE:

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