Uniform Certification Form PDF Details

In an effort to foster diversity and inclusion within the business environment, the Maryland Department of Transportation (MDOT) employs the Uniform Certification Application form under the auspices of the Disadvantaged Business Enterprise (DBE) Program, delineated by 49 C.F.R. Part 26. This meticulous form is crafted to assist businesses in determining their eligibility for certification as a minority or disadvantaged business enterprise, a process that promotes equitable participation in federal contracts and projects. Businesses assessing their eligibility must navigate through a series of prerequisites, including ownership, financial size standards, and the legal structuring of the company, ensuring that at least 51% owned by socially and economically disadvantaged individuals who exercise control over the business. Additionally, applicants are guided to attach necessary documentation and are provided with resources for further information, such as links to relevant websites and detailed instructions on completing the application. Furthermore, the form takes into account the business's history, relationships with other businesses, and the individual backgrounds of owners, aligning with the program’s drive to substantiate the disadvantaged status of applicants effectively. With sections devoted to prior certifications, the business profile, and detailed control and ownership information, the application offers a thorough roadmap for businesses aiming to validate their qualification for the U.S. DOT DBE program, highlighting the importance of transparency and thoroughness in the pursuit of fostering diversity and economic growth within the transportation sector.

QuestionAnswer
Form NameUniform Certification Form
Form Length23 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min 45 sec
Other namesDBE, Financial, certification dbe has, uniform certification

Form Preview Example

Maryland Department of Transportation

RETURN TO:

COMPLETE ALL ITEMS.

Minority Business Enterprise Office

If an item does not apply, mark

Maryland Department of Transportation

“N.A.”

7201 Corporate Center Dr.

Use separate sheet(s) for

Hanover, MD 21076

Additional information

410-865-1269

 

1-800-544-6056

 

DISADVANTAGED BUSINESS ENTERPRISE PROGRAM

49 C.F.R. PART 26

UNIFORM CERTIFICATION APPLICATION

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) size standard and does not exceed $22.41 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 U.S. DOT DBE program.

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

•Where can I find more information?

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)

oSBA – http://www.ntis.gov/naics (provides a listing of NAICS codes) and http://www.sba.gov/size/indextableofsize.html (provides a listing of SIC codes)

o49 CFR Part 26 (the rules and regulations governing the DBE program)

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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Maryland Department of Transportation

A. Prior/Other Certifications

Section 1: CERTIFICATION INFORMATION

Is your firm currently certified for any of the following programs?

If Yes, check appropriate box(es))

DBE

Name of certifying agency:

Has your firm's state UCP conducted an on-site visit?

Yes, on Date:

 

State:

 

No

8(a)

SDB

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 Date:

 

No

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

A.

Contact Information

Section 2: GENERAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) CONTACT PERSON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

(3) Phone #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4)

Other Phone

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2)

Legal name of firm:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(5)

Fax #:

(6) E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(7)

Website (if you have one):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8)

Street address of firm (No P.O.Boxes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address 1

 

 

 

City

 

 

 

 

County/Parish:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address 2

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(9) Mailing address of firm (if different):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address 1

 

 

City

 

 

 

 

County/Parish:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address 2

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.Business Profile

(1)

Describe the primary activities of your firm:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2)

Federal Tax ID (if any):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)

This firm was established on

Date:

 

 

 

 

(4)

I/We have owned this firm since

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(5)

Method of acquisition (check all that apply):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start 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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