Ga Uniform Application Form PDF Details

The Georgia Uniform Certification Application, pivotal for the Disadvantaged Business Enterprise (DBE) Program under 49 C.F.R. Part 26, offers a comprehensive channel for socially and economically disadvantaged individuals seeking certification through the Georgia Department of Transportation Equal Opportunity Division. It acts as a beacon for small businesses that are predominantly owned by minorities, ensuring they meet specific eligibility criteria relating to ownership, business size under the Small Business Administration (SBA) standards, and economic thresholds. This form not only simplifies the application process, especially for firms already possessing SBA 8(a) and/or SDB certifications through a streamlined process but also emphasizes the necessity of attaching all requisite documents for a complete application. Furthermore, it provides a clear pathway for applicants, guiding them through sections on general information, business profile, ownership, control, financial information, and the vital declarations that cement the credibility and eligibility of a business for the DBE program. Aligned with this, the form mandates an affidavit and a rigorous checklist that covers everything from personal net worth statements, tax returns, proof of contributions, to information about equipment, vehicles, and office spaces, underscoring the thoroughness required for DBE certification. Through this application process, businesses are held to a high standard of transparency and integrity, as any misinformation or false statements can lead to severe penalties, including suspension, debarment, or criminal prosecution, thereby ensuring only genuine disadvantaged businesses benefit from the program.

QuestionAnswer
Form NameGa Uniform Application Form
Form Length14 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 30 sec
Other namesga unifomr application, georgia uniform application pdf, georgia uniform application for credentialing, what is the georgia uniform application

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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.

Section 1: CERTIFICATION INFORMAITON

A.Prior/Other Certifications

Check the appropriate box indicating for which program your firm is currently certified. If you are already certified as a DBE, indicate in the appropriate box the name of the certifying agency that has previously certified your firm, and also indicate whether your firm has undergone an onsite visit. If your firm has already undergone an onsite visit/review, indicate the most recent date of that review and the state UCP that conducted the review.

NOTE: If your firm is currently certified under the SBA's 8(a) and/or SDB programs, you may not have to complete this application. You should contact your state UCP to find out about a streamlined application process for firms that are already certified under the 8(a) and SDB programs.

B.Prior/Other Applications and Privileges

Indicate whether your firm or any of the persons listed has ever withdrawn an application for a DBE program or an SBA 8(a) or SDB program, or whether any have ever been denied certification, decertified, debarred, suspended, or had bidding privileges denied or restricted by any state or local agency or Federal entity. If your answer is yes, indicate the date of such action, identify the name of the agency, and explain fully the nature of the action in the space provided.

Section 2: GENERAL INFORMATION

A.Contact Information

(A)State the name and title of the person who will serve as your firm's primary contact under this application.

(B)State the legal name of your firm, as indicated in your firm's Articles of Incorporation.

(C)Indicate the primary phone number of your firm.

(D)Indicate a secondary phone number, if any.

(E)Indicate your firm's fax number, if any.

(F)Indicate your firm's or your contact person's email address.

(G)Indicate your firm's website address, if any.

(H)State the street address of your firm (i.e. the physical location of its offices -- not a post office box address).

(I)State the mailing address of your firm, if it is different from your firm’s street address.

B.Business Profile

(1) In the box provided, briefly describe the primary business and professional activities in which your firm engages.

(2) Give the Federal Tax ID number of your firm as provided on your firm’s filed tax returns, if you have one. This could also be the Social Security number of the owner of your firm.

(3) Give the date on which your firm was officially established, as stated in your firm’s Articles of Incorporation.

(4) Give the date on which you and/or each other owner took ownership of the firm.

D.Immediate Family Member Businesses

Check the appropriate box that indicates whether any of your immediate family members own or manage another company. An “immediate family member” is any person who is your father, mother, husband, wife, son, daughter, brother, sister, grandmother, grandfather, grandson, granddaughter, mother-in-law, or father-in-law. If you answered “Yes,” provide the name of each relative, your

(5)Check the appropriate box that describes the manner in which you and each other owner acquired ownership of your firm. If you checked “Other,” explain in the space provided.

(6)Check the appropriate box that indicates whether your firm is “for profit.”

NOTE: If you checked “No,” then you do NOT qualify for the DBE program and therefore do not need to complete the rest of this application. The DBE program requires all participating firms be for-profit enterprises.

(7)Check the appropriate box that describes the legal form of ownership of your firm, as indicated in your firm’s Articles of Incorporation. If you checked “Other,” briefly explain in the space provided.

(8)Check the appropriate box that indicates whether your firm has ever existed under different ownership, a different type of ownership, or a different name. If you checked “Yes,” specify which and briefly explain the circumstances in the space provided.

(9)Indicate in the spaces provided how many employees your firm has, specifying the number of employees who work on a full-time and part-time basis.

(10)Specify the total gross receipts of your firm for each of the past three years, as declared in your firm’s filed tax returns.

C. Relationships with Other Businesses

(1)Check the appropriate box that indicates whether your firm is co-located at any of its business locations, or whether your firm shares a telephone number(s), a post office box, any office space, a yard, warehouse, other facilities, any equipment, or any office staff with any other business, organization, or entity of any kind. If you answered “Yes,” then specify the name of the other firm(s) and briefly explain the nature of the shared facilities or other items in the space provided.

(2)Check the appropriate box that indicates whether at present, or at any time in the past:

(a)your firm has been a subsidiary of any other firm;

(b)your firm consisted of a partnership in which one or more of the partners are other firms;

(c)your firm has owned any percentage of any other firm; and

(d)your firm has had any subsidiaries of its own.

(3)Check the appropriate box that indicates whether any other firm has ever had an ownership interest in your firm.

(4)If you answered “Yes” to any of the questions in (2)(a)-

(d)or (3), identify the name, address and type of business for each.

relationship to them, the name of the company they own or manage, the type of business, and whether they own or manage the company.

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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 your firm has more than one owner, provide completed copies of this section for each additional owner):

A.Background Information

(1)Give the name of the owner.

(2)State his/her title or position within your firm.

(3)Give his/her home phone number.

(4)State his/her home (street) address.

(5)Check the appropriate box that indicates this owner’s gender.

(6)Check the appropriate box that indicates this owner’s ethnicity (check all that apply). If you checked “Other,” specify this owner’s ethnic group/identity not otherwise listed.

(7)Check the appropriate box to indicate whether this owner is a U.S. citizen.

(8)If this owner is not a U.S. citizen, check the appropriate box that indicates whether this owner is a lawfully admitted permanent resident. If this owner is neither a U.S. citizen nor a lawfully admitted permanent resident of the U.S., then this owner is NOT eligible for certification as a DBE owner. This, however, does not necessarily disqualify your firm altogether from the DBE program if another owner is a U.S. citizen or lawfully admitted permanent resident and meets the program’s other qualifying requirements.

B.Ownership Interest

(1)State the number of years during which this owner has been an owner of your firm.

(2)Indicate the dollar value of this owner’s initial investment to acquire an ownership interest in your firm, broken down by cash, real estate, equipment, and/or other investment.

(3)State the percentage of total ownership control of your firm that this owner possesses.

(4)State the familial relationship of this owner to each other owner of your firm.

(5)Indicate the number, percentage of the total, class, date acquired, and method by which this owner acquired his/her shares of stock in your firm.

(6)Check the appropriate box that indicates whether this owner performs a management or supervisory function for any other business. If you checked “Yes,” state the name of the other business and this owner’s title or function held in that business.

(7)Check the appropriate box that indicates whether this owner owns or works for any other firm(s) that has any relationship with your firm. If you checked “Yes,” identify the name of the other business and this owner’s title or function held in that business. Briefly describe the nature of the business relationship in the space provided.

C.Disadvantaged Status

NOTE: You only need to complete this section for each owner that is applying for DBE qualification (i.e. for each owner who is claiming to be “socially and economically disadvantaged” and whose ownership interest is to be counted toward the control and 51% ownership requirements of the DBE program)

(1)Indicate in the space provided the total Personal Net Worth (PNW) of each owner who is applying for DBE qualification. Use the PNW calculator form at the end of this application to compute each owner’s PNW.

(2)Check the appropriate box that indicates whether any trust has ever been created for the benefit of this disadvantaged owner. If you answered “Yes,” briefly explain the nature, history, purpose, and current value of the trust(s).

Section 4: CONTROL

A.Identify your firm's Officers and Board of Directors:

(1)In the space provided, state the name, title, date of appointment, ethnicity, and gender of each officer of your firm.

(2)In the space provided, state the name, title, date of appointment, ethnicity, and gender of each individual serving on your firm’s Board of Directors.

(3)Check the appropriate box that indicates whether any of your firm’s officers and/or directors listed above perform a management or supervisory function for any other business. If you answered “Yes,” identify each person by name, his/her title, the name of the other business in which s/he is involved, and his/her function performed in that other business.

(4)Check the appropriate box that indicates whether any of your firm’s officers and/or directors listed above own or work for any other firm(s) that has a relationship with your firm. If you answered “Yes,” identify the name of the firm, the officer or director, and the nature of his/her business relationship with that other firm.

B.Identify your firm's management personnel (by name, title, ethnicity, and gender) who control your firm in the following areas:

(1)Making of financial decisions on your firm’s behalf, including the acquisition of lines of credit, surety bonds, supplies, etc.;

(2)Estimating and bidding, including calculation of cost estimates, bid preparation and submission;

(3)Negotiating and contract execution, including participation in any of your firm’s negotiations and executing contracts on your firm’s behalf;

(4)Hiring and/or firing of management personnel, including interviewing and conducting performance evaluations;

(5)Field/Production operations supervision, including site supervision, scheduling, project management services, etc.;

(6)Office management;

(7)Marketing and sales;

(8)Purchasing of major equipment;

(9)Signing company checks (for any purpose); and

(10)Conducting any other financial transactions on your firm’s behalf not otherwise listed.

(11)Check the appropriate box that indicates whether any of the persons listed in (1) through (10) above perform a management or supervisory function for any other business. If you answered “Yes,” identify each person by name, his/her title, the name of the other business in which s/he is involved, and his/her function performed in that other business.

(12)Check the appropriate box that indicates whether any of the persons listed in (1) through (10) above own or work for any other firm(s) that has a relationship with your firm. If you answered “Yes,” identify the name of the firm, the name of the person, and the nature of his/her business relationship with that other firm.

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C. Indicate your firm's inventory in the following categories:

A.Equipment

State the type, make and model, and current dollar value of each piece of equipment held and/or used by your firm. Indicate whether each piece is either owned or leased by your firm.

B.Vehicles

State the type, make and model, and current dollar value of each motor vehicle held and/or used by your firm. Indicate whether each vehicle is either owned or leased by your firm.

C.Office Space

State the street address of each office space held and/or used by your firm. Indicate whether your firm owns or leases the office space and the current dollar value of that property or its lease.

D.Storage Space

State the street address of each storage space held and/or used by your firm. Indicate whether your firm owns or leases the storage space and the current dollar value of that property or its lease.

D.Does your firm rely on any other firm for management functions or employee payroll?

Check the appropriate box that indicates whether your firm relies on any other firm for management functions or for employee payroll. If you answered “Yes,” briefly explain the nature of that reliance and the extent to which the other firm carries out such functions.

E.Financial Information

(1) Banking Information

(a)State the name of your firm’s bank.

(b)Give the main phone number of your firm’s bank branch.

(c)Give the address of your firm’s bank branch.

(2) Bonding Information

(a)State your firm’s Binder Number.

(b)State the name of your firm’s bond agent and/or broker.

(c)Give your agent’s/broker’s phone number.

(d)Give your agent’s/broker’s address.

(e)State your firm’s bonding limits (in dollars), specifying both the Aggregate and Project Limits.

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

State the name and address of each source, the original dollar amount and the current balance of each loan, and the purpose for which each loan was made to your firm.

G.List all contributions or transfers of assets to/from your firm and to/from any of its owners over the past two years:

Indicate in the spaces provided, the type of contribution or asset that was transferred, its current dollar value, the person or firm from whom it was transferred, the person or firm to whom it was transferred, the relationship between the two persons and/or firms, and the date of the transfer.

H.List current licenses/permits held by any owner or employee of your firm.

List the name of each person in your firm who holds a professional license or permit, the type of permit or license, the expiration date of the permit or license, and the license/permit number and issuing State of the license or permit.

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

List the name of each owner or contractor for each contract, the name and location of the projects under each contract, the type of work performed on each contract, and the dollar value of each contract.

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

For each active job listed, state the name of the prime contractor and the project number, the location, the type of work performed, the project start date, the anticipated completion date, and the dollar value of the contract.

AFFIDAVIT & SIGNATURE

Carefully read the attached affidavit in its entirety. Fill in the required information for each blank space, and sign and date the affidavit in the presence of a Notary Public, who must then notarize the form.

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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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(11) Do any of the persons listed in (1) through (10) above perform a management or supervisory function for any other business? Yes No
If Yes, identify for each: Person: __________________________________ Title: ______________________________
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Section 4: CONTROL

A.Identify your firm’s Officers & Board of Directors (If additional space is required, attach a separate sheet):

Name

Title

Date Appointed

Ethnicity

Gender

(1) Officers

(a)

of the

 

(b)

Company

(c)

 

 

(d)

 

(e)

(2) Board of

(a)

Directors

 

(b)

 

 

(c)

 

(d)

 

(e)

(3)Do any of the persons listed in (1) and/or (2) above perform a management or supervisory function for any other business? Yes No

If Yes, identify for each: Person: __________________________________ Title: ______________________________

Business: ________________________________ Function: ___________________________

(4)Do any of the persons listed (1) and/or (2) 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:

B.Identify your firm’s management personnel who control your firm in the following areas (If more than two persons, attach a separate sheet):

 

 

Name

Title

Ethnicity

Gender

 

 

 

 

 

 

(1)

Financial Decisions

a.

 

 

 

(responsibility for acquisition of lines of

 

 

 

 

b.

 

 

 

credit, surety bonding, supplies, etc.)

 

 

 

 

 

 

 

(2)

Estimating and bidding

a.

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

(3)

Negotiating and Contract

a.

 

 

 

Execution

 

 

 

 

b.

 

 

 

(4)

Hiring/firing of management

a.

 

 

 

personnel

 

 

 

 

b.

 

 

 

(5)

Field/Production Operations

a.

 

 

 

Supervisor

 

 

 

 

b.

 

 

 

(6)

Office management

a.

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

(7)

Marketing/Sales

a.

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

(8)

Purchasing of major

a.

 

 

 

equipment

 

 

 

 

b.

 

 

 

(9)

Authorized to Sign Company

a.

 

 

 

Checks (for any purpose)

 

 

 

 

b.

 

 

 

(10) Authorized to make

a.

 

 

 

Financial Transactions

 

 

 

 

b.

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

8

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.

 

 

 

 

 

 

 

 

 

 

 

9

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:

11