Instructions for "Disadvantaged Business Enterprise (Dbe) Program Uniform Certification Application" - Connecticut

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INSTRUCTIONS FOR COMPLETING THE DISADVANTAGED BUSINESS ENTERPRISE (DBE)
PROGRAM 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
(4) Give the date on which you and/or each other
owner took ownership of the firm.
A. Prior/Other Certifications
Check the appropriate box indicating for which
(5) Check the appropriate box that describes the
program your firm is currently certified. If you are
manner in which you and each other owner
already certified as a DBE, indicate in the appropriate
acquired ownership of your firm. If you checked
box the name of the certifying agency that has
“Other,” explain in the space provided.
previously certified your firm, and also indicate
(6) Check the appropriate box that indicates whether
whether your firm has undergone an onsite visit. If
your firm is “for profit.”
your
firm
has
already
undergone
an
onsite
NOTE: If you checked “No,” then you do NOT
visit/review, indicate the most recent date of that
qualify for the DBE program and therefore do not
review and the state UCP that conducted the review.
need to complete the rest of this application. The
NOTE: If your firm is currently certified under the
DBE program requires all participating firms be
SBA's 8(a) and/or SDB programs, you may not have
for-profit enterprises.
to complete this application. You should contact your
(7) Check the appropriate box that describes the legal
state UCP to find out about a streamlined application
form of ownership of your firm, as indicated in
process for firms that are already certified under the
your firm’s Articles of Incorporation.
If you
8(a) and SDB programs.
checked “Other,” briefly explain in the space
provided.
B.
Prior/Other Applications and Privileges
Indicate whether your firm or any of the persons listed
(8) Check the appropriate box that indicates whether
has ever withdrawn an application for a DBE program
your firm has ever existed under different
or an SBA 8(a) or SDB program, or whether any have
ownership, a different type of ownership, or a
ever been denied certification, decertified, debarred,
different name. If you checked “Yes,” specify
suspended, or had bidding privileges denied or
which and briefly explain the circumstances in
restricted by any state or local agency or Federal
the space provided.
entity. If your answer is yes, indicate the date of such
(9) Indicate in the spaces provided how many
action, identify the name of the agency, and explain
employees your firm has, specifying the number
fully the nature of the action in the space provided.
of employees who work on a full-time and part-
time basis.
(10) Specify the total gross receipts of your firm for
Section 2: GENERAL INFORMATION
each of the past three years, as declared in your
A. Contact Information
(1) State the name and title of the person who will
firm’s filed tax returns.
serve as your firm's primary contact under this
C. Relationships with Other Businesses
application.
(1) Check the appropriate box that indicates whether
(2) State the legal name of your firm, as indicated in
your firm is co-located at any of its business
your firm's Articles of Incorporation.
locations, or whether your firm shares a
(3) Indicate the primary phone number of your firm.
telephone number(s), a post office box, any office
(4) Indicate a secondary phone number, if any.
space, a yard, warehouse, other facilities, any
(5) Indicate your firm's fax number, if any.
equipment, or any office staff with any other
(6) Indicate your firm's or your contact person's
business, organization, or entity of any kind. If
email address.
you answered “Yes,” then specify the name of
(7) Indicate your firm's website address, if any.
the other firm(s) and briefly explain the nature of
(8) State the street address of your firm (i.e. the
the shared facilities or other items in the space
physical location of its offices -- not a post office
provided.
box address).
(2) Check the appropriate box that indicates whether
(9) State the mailing address of your firm, if it is
at present, or at any time in the past:
different from your firm’s street address.
(a) your firm has been a subsidiary of any
B.
Business Profile
other firm;
(1) In the box provided, briefly describe the primary
(b) your firm consisted of a partnership in
business and professional activities in which your
which one or more of the partners are
firm engages.
other firms;
(2) Give the Federal Tax ID number of your firm as
(c) your firm has owned any percentage of
provided on your firm’s filed tax returns, if you
any other firm; and
have one. This could also be the Social Security
(d) your firm has had any subsidiaries of
number of the owner of your firm.
its own.
(3) Give the date on which your firm was officially
(3) Check the appropriate box that indicates whether
established, as stated in your firm’s Articles of
any other firm has ever had an ownership interest
Incorporation.
in your firm.
i
INSTRUCTIONS FOR COMPLETING THE DISADVANTAGED BUSINESS ENTERPRISE (DBE)
PROGRAM 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
(4) Give the date on which you and/or each other
owner took ownership of the firm.
A. Prior/Other Certifications
Check the appropriate box indicating for which
(5) Check the appropriate box that describes the
program your firm is currently certified. If you are
manner in which you and each other owner
already certified as a DBE, indicate in the appropriate
acquired ownership of your firm. If you checked
box the name of the certifying agency that has
“Other,” explain in the space provided.
previously certified your firm, and also indicate
(6) Check the appropriate box that indicates whether
whether your firm has undergone an onsite visit. If
your firm is “for profit.”
your
firm
has
already
undergone
an
onsite
NOTE: If you checked “No,” then you do NOT
visit/review, indicate the most recent date of that
qualify for the DBE program and therefore do not
review and the state UCP that conducted the review.
need to complete the rest of this application. The
NOTE: If your firm is currently certified under the
DBE program requires all participating firms be
SBA's 8(a) and/or SDB programs, you may not have
for-profit enterprises.
to complete this application. You should contact your
(7) Check the appropriate box that describes the legal
state UCP to find out about a streamlined application
form of ownership of your firm, as indicated in
process for firms that are already certified under the
your firm’s Articles of Incorporation.
If you
8(a) and SDB programs.
checked “Other,” briefly explain in the space
provided.
B.
Prior/Other Applications and Privileges
Indicate whether your firm or any of the persons listed
(8) Check the appropriate box that indicates whether
has ever withdrawn an application for a DBE program
your firm has ever existed under different
or an SBA 8(a) or SDB program, or whether any have
ownership, a different type of ownership, or a
ever been denied certification, decertified, debarred,
different name. If you checked “Yes,” specify
suspended, or had bidding privileges denied or
which and briefly explain the circumstances in
restricted by any state or local agency or Federal
the space provided.
entity. If your answer is yes, indicate the date of such
(9) Indicate in the spaces provided how many
action, identify the name of the agency, and explain
employees your firm has, specifying the number
fully the nature of the action in the space provided.
of employees who work on a full-time and part-
time basis.
(10) Specify the total gross receipts of your firm for
Section 2: GENERAL INFORMATION
each of the past three years, as declared in your
A. Contact Information
(1) State the name and title of the person who will
firm’s filed tax returns.
serve as your firm's primary contact under this
C. Relationships with Other Businesses
application.
(1) Check the appropriate box that indicates whether
(2) State the legal name of your firm, as indicated in
your firm is co-located at any of its business
your firm's Articles of Incorporation.
locations, or whether your firm shares a
(3) Indicate the primary phone number of your firm.
telephone number(s), a post office box, any office
(4) Indicate a secondary phone number, if any.
space, a yard, warehouse, other facilities, any
(5) Indicate your firm's fax number, if any.
equipment, or any office staff with any other
(6) Indicate your firm's or your contact person's
business, organization, or entity of any kind. If
email address.
you answered “Yes,” then specify the name of
(7) Indicate your firm's website address, if any.
the other firm(s) and briefly explain the nature of
(8) State the street address of your firm (i.e. the
the shared facilities or other items in the space
physical location of its offices -- not a post office
provided.
box address).
(2) Check the appropriate box that indicates whether
(9) State the mailing address of your firm, if it is
at present, or at any time in the past:
different from your firm’s street address.
(a) your firm has been a subsidiary of any
B.
Business Profile
other firm;
(1) In the box provided, briefly describe the primary
(b) your firm consisted of a partnership in
business and professional activities in which your
which one or more of the partners are
firm engages.
other firms;
(2) Give the Federal Tax ID number of your firm as
(c) your firm has owned any percentage of
provided on your firm’s filed tax returns, if you
any other firm; and
have one. This could also be the Social Security
(d) your firm has had any subsidiaries of
number of the owner of your firm.
its own.
(3) Give the date on which your firm was officially
(3) Check the appropriate box that indicates whether
established, as stated in your firm’s Articles of
any other firm has ever had an ownership interest
Incorporation.
in your firm.
i
(4) If you answered “Yes” to any of the questions in
(6) Check the appropriate box that indicates whether
(2)(a)-(d) or (3), identify the name, address and
this
owner
performs
a
management
or
type of business for each.
supervisory function for any other business. If
D. Immediate Family Member Businesses
you checked “Yes,” state the name of the other
Check the appropriate box that indicates whether any
business and this owner’s title or function held in
of your immediate family members own or manage
that business.
another company. An “immediate family member” is
(7) Check the appropriate box that indicates whether
any person who is your father, mother, husband, wife,
this owner owns or works for any other firm(s)
son,
daughter,
brother,
sister,
grandmother,
that has any relationship with your firm. If you
grandfather, grandson, granddaughter, mother-in-law,
checked “Yes,” identify the name of the other
or father-in-law. If you answered “Yes,” provide the
business and this owner’s title or function held in
name of each relative, your relationship to them, the
that business. Briefly describe the nature of the
name of the company they own or manage, the type of
business relationship in the space provided.
business, and whether they own or manage the
C. Disadvantaged Status
company.
NOTE: You only need to complete this section for
each owner that is applying for DBE qualification
Section 3: OWNERSHIP
(i.e. for each owner who is claiming to be “socially
Identify all individuals or holding companies with any
and economically disadvantaged” and whose
ownership interest in your firm, providing the
ownership interest is to be counted toward the
information requested below (if your firm has more
control and 51% ownership requirements of the
than one owner, provide completed copies of this section
DBE program)
for each additional owner):
(1) Indicate in the space provided the total Personal
A.
Background Information
Net Worth (PNW) of each owner who is applying
(1) Give the name of the owner.
for DBE qualification. Use the PNW calculator
(2) State his/her title or position within your firm.
form at the end of this application to compute
(3) Give his/her home phone number.
each owner’s PNW.
(4) State his/her home (street) address.
(2) Check the appropriate box that indicates whether
(5) Check the appropriate box that indicates this
any trust has ever been created for the benefit of
owner’s gender.
this disadvantaged owner.
If you answered
(6) Check the appropriate box that indicates this
“Yes,” briefly explain the nature, history,
owner’s ethnicity (check all that apply). If you
purpose, and current value of the trust(s).
checked “Other,” specify this owner’s ethnic
group/identity not otherwise listed.
Section 4: CONTROL
(7) Check the appropriate box to indicate whether
A. Identify your firm's Officers and Board of
this owner is a U.S. citizen.
Directors:
(8) If this owner is not a U.S. citizen, check the
(1) In the space provided, state the name, title, date
appropriate box that indicates whether this owner
of appointment, ethnicity, and gender of each
is a lawfully admitted permanent resident. If this
officer of your firm.
owner is neither a U.S. citizen nor a lawfully
(2) In the space provided, state the name, title, date
admitted permanent resident of the U.S., then this
of appointment, ethnicity, and gender of each
owner is NOT eligible for certification as a DBE
individual serving on your firm’s Board of
owner.
This, however, does not necessarily
Directors.
disqualify your firm altogether from the DBE
(3) Check the appropriate box that indicates whether
program if another owner is a U.S. citizen or
any of your firm’s officers and/or directors listed
lawfully admitted permanent resident and meets
above perform a management or supervisory
the program’s other qualifying requirements.
function for any other business. If you answered
B.
Ownership Interest
“Yes,” identify each person by name, his/her title,
(1) State the number of years during which this
the name of the other business in which s/he is
owner has been an owner of your firm.
involved, and his/her function performed in that
(2) Indicate the dollar value of this owner’s initial
other business.
investment to acquire an ownership interest in
(4) Check the appropriate box that indicates whether
your firm, broken down by cash, real estate,
any of your firm’s officers and/or directors listed
equipment, and/or other investment.
above own or work for any other firm(s) that has
(3) State the percentage of total ownership control of
a relationship with your firm. If you answered
your firm that this owner possesses.
“Yes,” identify the name of the firm, the officer
(4) State the familial relationship of this owner to
or director, and the nature of his/her business
each other owner of your firm.
relationship with that other firm.
(5) Indicate the number, percentage of the total,
B.
Identify your firm's management personnel (by
class, date acquired, and method by which this
name, title, ethnicity, and gender) who control your
owner acquired his/her shares of stock in your
firm in the following areas:
firm.
2
(1) Making of financial decisions on your firm’s
“Yes,” briefly explain the nature of that reliance and
behalf, including the acquisition of lines of credit,
the extent to which the other firm carries out such
surety bonds, supplies, etc.;
functions.
(2) Estimating and bidding, including calculation of
E.
Financial Information
cost estimates, bid preparation and submission;
(1) Banking Information
(3) Negotiating and contract execution, including
(a) State the name of your firm’s bank.
participation in any of your firm’s negotiations
(b) Give the main phone number of your
and executing contracts on your firm’s behalf;
firm’s bank branch.
(4) Hiring and/or firing of management personnel,
(c) Give the address of your firm’s bank
including
interviewing
and
conducting
branch.
performance evaluations;
(2) Bonding Information
(5) Field/Production
operations
supervision,
(a) State your firm’s Binder Number.
including site supervision, scheduling, project
(b) State the name of your firm’s bond
management services, etc.;
agent and/or broker.
(6) Office management;
(c) Give
your
agent’s/broker’s
phone
(7) Marketing and sales;
number.
(8) Purchasing of major equipment;
(d) Give your agent’s/broker’s address.
(9) Signing company checks (for any purpose); and
(e) State your firm’s bonding limits (in
(10) Conducting any other financial transactions on
dollars), specifying both the Aggregate
your firm’s behalf not otherwise listed.
and Project Limits.
(11) Check the appropriate box that indicates whether
F.
Identify all sources, amounts, and purposes of
any of the persons listed in (1) through (10)
money loaned to your firm, including the names of
above perform a management or supervisory
persons or firms securing the loan, if other than the
function for any other business. If you answered
listed owner:
“Yes,” identify each person by name, his/her title,
State the name and address of each source, the original
the name of the other business in which s/he is
dollar amount and the current balance of each loan,
involved, and his/her function performed in that
and the purpose for which each loan was made to your
other business.
firm.
(12) Check the appropriate box that indicates whether
G. List all contributions or transfers of assets to/from
any of the persons listed in (1) through (10)
your firm and to/from any of its owners over the
above own or work for any other firm(s) that has
past two years:
a relationship with your firm. If you answered
Indicate in the spaces provided, the type of
“Yes,” identify the name of the firm, the name of
contribution or asset that was transferred, its current
the person, and the nature of his/her business
dollar value, the person or firm from whom it was
relationship with that other firm.
transferred, the person or firm to whom it was
C. Indicate your firm's inventory in the following
transferred, the relationship between the two persons
categories:
and/or firms, and the date of the transfer.
(1) Equipment
H. List current licenses/permits held by any owner or
State the type, make and model, and current
employee of your firm.
dollar value of each piece of equipment held
List the name of each person in your firm who holds a
and/or used by your firm. Indicate whether each
professional license or permit, the type of permit or
piece is either owned or leased by your firm.
license, the expiration date of the permit or license,
(2) Vehicles
and the license/permit number and issuing State of the
State the type, make and model, and current
license or permit.
dollar value of each motor vehicle held and/or
I.
List the three largest contracts completed by your
used by your firm. Indicate whether each vehicle
firm in the past three years, if any.
is either owned or leased by your firm.
List the name of each owner or contractor for each
(3) Office Space
contract, the name and location of the projects under
State the street address of each office space held
each contract, the type of work performed on each
and/or used by your firm. Indicate whether your
contract, and the dollar value of each contract.
firm owns or leases the office space and the
J.
List the three largest active jobs on which your
current dollar value of that property or its lease.
firm is currently working.
For each active job listed, state the name of the prime
(4) Storage Space
State the street address of each storage space held
contractor and the project number, the location, the
and/or used by your firm. Indicate whether your
type of work performed, the project start date, the
firm owns or leases the storage space and the
anticipated completion date, and the dollar value of
current dollar value of that property or its lease.
the contract.
D. Does your firm rely on any other firm for
AFFIDAVIT & SIGNATURE
management functions or employee payroll?
Carefully read the attached affidavit in its entirety.
Check the appropriate box that indicates whether your
Fill in the required information for each blank space,
firm relies on any other firm for management
and sign and date the affidavit in the presence of a
functions or for employee payroll. If you answered
Notary Public, who must then notarize the form.
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