Uniform Certification Application Form – Fill Out and Use This PDF

Section 1: CERTIFICATION INFORMATION

A.Basic Contact Information

(1)Enter the contact name and title of the person completing this application and the person who will serve as your firm's contact for this application.

(2)Enter the legal name of your firm, as indicated in your firm’s Articles of Incorporation or charter.

(3)Enter the primary phone number of your firm.

(4)Enter a secondary phone number, if any.

(5)Enter your firm’s fax number, if any.

(6)Enter the contact person's email address.

(7)Enter your firm’s website addresses, if any.

(8)Enter the street address of the firm where its offices are physically located (not a P.O. Box).

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

B.Prior/Other Certifications and Applications

(10)Check the appropriate box indicating whether your firm is currently certified in the DBE/ACDBE programs, and provide the name of the certifying agency that certified your firm. List the dates of any site visits conducted by your home state and any other states or UCP members. Also provide the names of state/UCP members that conducted the review.

(11)Indicate whether your firm or any firms owned by the persons listed has ever been denied certification as a DBE/ACDBE, 8(a), or Small Disadvantaged Business (SDB) firm, or state and local MBE/WBE firm. Indicate if the firm has ever been decertified from one of these programs. Indicate if the application was withdrawn or whether the firm was debarred, suspended, or otherwise had its bidding privileges denied or restricted by any state or local agency, or Federal entity. If your answer is yes, identify the name of the agency, and explain fully the nature of the action in the space provided. Indicate if you have ever appealed this decision to the Department and if so, attach a copy of USDOT’s final agency decision(s).

Section 2: GENERAL INFORMATION

A. Business profile:

(1)Give a concise description of the firm’s primary activities, the product(s) or services the company provides, or type of construction. If your company offers more than one product/service, list primary product or service first (attach additional sheets if necessary). This description may be used in our UCP online directory if you are certified as a DBE.

(2)If you know the appropriate NAICS Code for the line(s) of work you identified in your business profile, enter the codes in the space provided.

(3)State the date on which your firm was established as stated in your firm’s Articles of Incorporation or charter.

(4)State the date each person became a firm owner.

(5)Check the appropriate box describing 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.” If you checked “No,” then you do NOT qualify for the DBE/ACDBE program and should not complete this application. All participating firms must be for-profit enterprises. Provide the Federal Tax ID number as stated on your firm’s Federal tax return.

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

(8)Indicate in the spaces provided how many employees your firm has, specifying the number of employees who work on a full-time, part-time, and seasonal basis. Attach a list of employees, their job titles, and dates of employment, to your application.

(9)Specify the firm’s gross receipts for each of the past three years, as stated in your firm’s filed Federal tax returns. You must submit complete copies of the firm’s Federal tax returns for each year. If there are any affiliates or subsidiaries of the applicant firm or owners, you must provide these firms’ gross receipts and submit complete copies of these firm(s) Federal tax returns. Affiliation is defined in 49 C.F.R. §26.5 and 13 C.F.R. Part 121.

B.Relationships and Dealings 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, financing, or any office staff and/or employees with any other business, organization or entity of any kind. If you answered “Yes,” then specify the name of the other firm(s) and fully explain the nature of your relationship with these other businesses by identifying the business or person with whom you have any formal, informal, written, or oral

agreement. Provide an explanation of any items shared with other firms in the space provided.

(2)Check the appropriate box indicating whether any other firm currently has or had an ownership interest in your firm at present or at any time in the past. If you checked yes, please explain.

(3)Check the appropriate box that indicates whether at

present or at any time in the past your firm:

(a)ever existed under different ownership, a different type of ownership, or a different name;

(b)existed as a subsidiary of any other firm;

(c)existed as a partnership in which one or more of the partners are/were other firms;

(d)owned any percentage of any other firm; and

(e)had any subsidiaries of its own.

(f)served as a subcontractor with another firm constituting more than 25% of your firm’s receipts.

If you answered “Yes” to any of the questions in (3)(a-f), you may be asked to explain the arrangement in detail.

Section 3: MAJORITY OWNER INFORMATION

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 owner):

A. Identify the majority owner of the firm holding 51% or more ownership interest

(1)Enter the full name of the owner.

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

(3)Give his/her home phone number.

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

(5)Indicate this owner’s gender.

(6)Identify the owner’s ethnic group membership. 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 or 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.

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

(9)Indicate the percentage of the total ownership this person holds and the date acquired, including (if appropriate), the class of stock owned.

(10)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. Describe how you acquired your business and attach documentation substantiating this investment.

B. Additional Owner Information

(1)Describe the familial relationship of this owner to each other owner of your firm and employees.

(2)Indicate 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 function/title held in that business.

(3)(a) 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, the nature of the business relationship, and the owner’s function at the firm.

(b)If the owner works for any other firm, non-profit organization, or is engaged in any other activity more than 10 hours per week, please identify this activity.

(4)(a) Provide the personal net worth of the owner applying for certification in the space provided. Complete and attach the accompanying “Personal Net Worth Statement for DBE/ACDBE Program Eligibility” with your application. Note, complete this section and accompanying statement only for each owner applying

for DBE qualification (i.e., for each owner claiming to be socially and economically disadvantaged).

(b)Check the appropriate box that indicates whether any trust has been created for the benefit of the

disadvantaged owner(s). If you answered “Yes,” you may be asked to provide a copy of the trust instrument.

(5)Check the appropriate to indicate whether any of your immediate family members, managers, or employees, own, manage, or are associated with another company. Immediate family member is defined in 49 C.F.R.

§26.5. If you answered “Yes,” provide the name of each person, your relationship to them, the name of the company, the type of business, and whether they own or manage the company.

Section 4: CONTROL

A.Identify the 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.

(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 to indicate whether any of your firm’s officers and/or directors listed above performs 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. (e.g., ownership interest, shared office space, financial investments, equipment leases, personnel sharing, etc.) If you answered “Yes,” identify the name of the firm, the individual’s name, and the nature of his/her business relationship with that other firm.

B. Duties of Owners, Officers, Directors, Managers and Key Personnel

(1), (2) Specify the roles of the majority and minority owners, directors, officers, and managers, and key personnel who are responsible for the functions listed for the firm. Submit résumés for each owner and non-owner identified below. State the name of the individual, title, race

and gender and percentage ownership if any. Circle the frequency of each person’s involvement as follows: “always, frequently, seldom, or never” in each area.

Indicate whether any of the persons listed in this section perform a management or supervisory function for any other business. Identify the person, business, and their title/function. Identify if any of the persons listed above own or work for any other firm(s) that has a relationship with this firm (e.g. ownership interest, shared office space, financial investment, equipment, leases, personnel sharing, etc.) If you answered “Yes,” describe the nature of his/her business relationship with that other firm.

C. Inventory: Indicate firm inventory in these categories:

(1)Equipment and Vehicles

State the make and model, and current dollar value of each piece of equipment and motor vehicle held and/or used by your firm. Indicate whether each piece is either owned or leased by your firm or owner, whether it is used as collateral, and where this item is stored.

(2)Office Space

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

(3)Storage Space

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

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,” you may be asked to explain the nature of that reliance and the extent to which the other firm carries out such functions.

E. Financial / Banking Information

State the name, City and State of your firm’s bank. Identify the persons able to sign checks on this account. Provide bank authorization and signature cards.

Bonding Information. State your firm’s bonding limits both aggregate and project limits.

F. Sources, amounts, and purposes of money loaned to your firm, including the names of persons or firms guaranteeing the loan.

State the name and address of each source, the name of person securing the loan, original dollar amount and the current balance of each loan, and the purpose for which each

loan was made to your firm. Provide copies of signed loan agreements and security agreements

G. Contributions or transfers of assets to/from your firm and to/from any of its owners or another individual 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. 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 issuing State of the license or permit. Attach copies of licenses, license renewal forms, permits, and haul authority forms.

I. 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. 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.

Section 5: AIRPORT CONCESSION (ACDBE)

APPLICANTS

Complete the entries in this section if you are applying for ACDBE certification. Indicate in Section A if you operate a concession at the airport, and/or supply a good or service to an airport concessionaire. Indicate in Section B whether the applicant firm owns or operates any off-airport locations, providing the type of business, lease information, address/location, and annual gross receipts generated. Provide similar information in section C for any airport concession locations the firm currently owns or operates. If the applicant firm has any affiliates, provide the requested information in Section D. Indicate whether the ACDBE firm is participating in any joint ventures, and if so, include the original and any amended joint venture agreements.

AFFIDAVIT & SIGNATURE

The Affidavit of Certification must accompany your application. 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.

(1)Contact person and Title:

____________________

_____________________

(3)Phone #: (___) _____ - _______

(2)Legal name of firm: _________________________

_____________________________________________

(4)Other Phone #: (____) _____ - _____ (5) Fax #: (____) ______ - _____

(3) This firm was established on ___/____/____

(4) I/We have owned this firm since: ____/____/____

(6) Is your firm “for profit”? Yes Federal Tax ID#

________________________

No→ ⊗ STOP! If your firm is NOT for-profit, then you do NOT qualify for this program and should not fill out this application.

(1)Full Name:

______________________________

(2)Title:

_________________________

(3) Home Phone #:

( ) _____ - __________________

Type of Business

(e.g., F&B, News & Gift, Retail,

Duty Free, Advertising, etc.)

Lease Lease

Term Start

(years) Date

Address / Location

Annual Gross

Receipts Generated

Airport Name

Concession Type

(e.g., F&B, News &

Gift, Retail, Duty Free,

Advertising, etc.)

Number of Number of Leases Locations

Annual Gross

Receipts

Generated

Lease Type

(e.g. Direct Lease, Subcontract Management Agreement, etc. enter all that apply to the leases listed)

I ________________________________ (full name printed),

swear or affirm under penalty of law that I am

___________________________(title) of the applicant firm

__________________________________________ 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, subcontract, concession lease or sublease, 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 of any material change in the information contained in the original application within 30 calendar days of such change (e.g., ownership changes, address/telephone number, personal net worth exceeding $1.32 million, 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 or Airport Concession Disadvantaged Business Enterprise. 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): (Check all that apply):

Female Black American Hispanic American

Native American  Asian-Pacific American

Subcontinent Asian American  Other (specify)

____________________________________________

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 $1.32 million, 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.

Required Documents for All Applicants

Résumés (that include places of employment with corresponding dates), for all owners, officers, and key personnel of the applicant firm

Personal Net Worth Statement for each socially and economically disadvantaged owners who the applicant firm relies upon to satisfy the Regulation’s 51% ownership requirement.

Personal Federal tax returns for the past 3 years, if applicable, for each disadvantaged owner

Federal tax returns (and requests for extensions) filed by the firm and its affiliates with related schedules, for the past 3 years.

Documented proof of contributions used to acquire ownership for each owner (e.g., both sides of cancelled

checks)

Signed loan and security agreements, and bonding forms

List of equipment and/or vehicles owned and leased including VIN numbers, copy of titles, proof of ownership, insurance cards for each vehicle.

Title(s), registration certificate(s), and U.S. DOT numbers for each truck owned or operated by your firm

Licenses, license renewal forms, permits, and haul authority forms

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

Documented proof of any transfers of assets to/from your firm and/or to/from any of its owners over the past 2 years DBE/ACDBE and SBA 8(a), SDB, MBE/WBE certifications, denials, and/or decertification’s, if applicable; and any U.S. DOT appeal decisions on these actions.

Bank authorization and signatory cards

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

List of all employees, job titles, and dates of employment. Proof of warehouse/storage facility ownership or lease

arrangements

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 firm’s stock transfer ledger

Shareholders’ Agreement(s)

Minutes of all stockholders and board of director’s 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)

Optional Documents to Be Provided on Request

The certifying agency to which you are applying may require the submission of the following documents. If requested to provide these document, you must supply them with your application or at the on-site visit.

Proof of citizenship

Insurance agreements for each truck owned or operated by your firm

Audited financial statements (if available)

Trust agreements held by any owner claiming disadvantaged status

Year-end balance sheets and income statements for the past 3 years (or life of firm, if less than three years)

Suppliers

List of product lines carried and list of distribution equipment owned and/or leased