Form DGS PD812 "Request for Small Business, Small Business for the Purpose of Public Works and/Or Disabled Veteran Business Enterprise Certification (Application)" - California

What Is Form DGS PD812?

This is a legal form that was released by the California Department of General Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the California Department of General Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DGS PD812 by clicking the link below or browse more documents and templates provided by the California Department of General Services.

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Download Form DGS PD812 "Request for Small Business, Small Business for the Purpose of Public Works and/Or Disabled Veteran Business Enterprise Certification (Application)" - California

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Page 1
State of California
Department of General Services
FOR STATE USE ONLY
Procurement Division
Request for Small Business, Small Business for the Purpose of
Public Works and/or Disabled Veteran Business Enterprise
CERTIFICATION ID:
Certification (Application)
BIDDER ID:
DGS PD 812 (Rev. 09/2019)
Formerly STD 812
CERT. OFFICER:
DATE RECEIVED:
Office of Small Business & DVBE Services (OSDS)
DATE PROCESSED:
707 3rd Street, 1st Floor, Room 1-400, MS 210
West Sacramento, CA 95605
Cal eProcure Webpage ▪ (916) 375-4940 ▪ FAX (916) 375-4950 ▪
OSDSHelp@dgs.ca.gov
ONLINE APPLICATIONS CAN HAVE A SHORTER PROCESSING TIME.
GO TO THE
CAL EPROCURE WEB PAGE
SUBMISSION OF PAPER REQUESTS MAY SIGNIFICANTLY
LENGTHEN PROCESSING TIMES.
APPLICANT MUST BE AN ESTABLISHED BUSINESS BEFORE APPLYING. TYPE OR PRINT
CLEARLY IN INK.
1. CERTIFICATION TYPE (Check at least one below) Renewal applications should only be submitted
within 90 days prior to the firm’s certification expiration date.)
□ SMALL BUSINESS
□ SMALL BUSINESS-PUBLIC
□ DISABLED VETERAN
(SB)
WORKS (SB-PW)
BUSINESS ENTERPRISE (DVBE)
Owner/officer must sign
Owner/officer must sign Section N
Disabled Veteran qualifier (DV)
Section N
must sign Sections N and O
A. REGISTRATION & CONTACT INFORMATION (ALL APPLICANTS)
2. LEGAL BUSINESS NAME
3. PRIMARY “DOING BUSINESS AS” (DBA)
NAME, IF ANY
4. SECONDARY “DOING BUSINESS AS” (DBA)
NAME, IF ANY
5. FEDERAL EMPLOYER IDENTIFICATION
6. OWNER’S SOCIAL SECURITY NUMBER
NUMBER (FEIN)
(SSN) (Only for sole proprietorships that
do not use a FEIN)
7. OFFICE MAILING ADDRESS
CITY (Required)
STATE
ZIP CODE
COUNTY
(Required)(Street address or P.O. Box)
(Required)
(Required)
Do not leave blank.
CITY (Required)
8. PHYSICAL ADDRESS OF PRINCIPAL
STATE
ZIP CODE
COUNTY
(Required)
(Required)
OFFICE (Required)(Do not use P.O.
Do not leave blank.
Box.)
Do not leave blank.
Page 1
State of California
Department of General Services
FOR STATE USE ONLY
Procurement Division
Request for Small Business, Small Business for the Purpose of
Public Works and/or Disabled Veteran Business Enterprise
CERTIFICATION ID:
Certification (Application)
BIDDER ID:
DGS PD 812 (Rev. 09/2019)
Formerly STD 812
CERT. OFFICER:
DATE RECEIVED:
Office of Small Business & DVBE Services (OSDS)
DATE PROCESSED:
707 3rd Street, 1st Floor, Room 1-400, MS 210
West Sacramento, CA 95605
Cal eProcure Webpage ▪ (916) 375-4940 ▪ FAX (916) 375-4950 ▪
OSDSHelp@dgs.ca.gov
ONLINE APPLICATIONS CAN HAVE A SHORTER PROCESSING TIME.
GO TO THE
CAL EPROCURE WEB PAGE
SUBMISSION OF PAPER REQUESTS MAY SIGNIFICANTLY
LENGTHEN PROCESSING TIMES.
APPLICANT MUST BE AN ESTABLISHED BUSINESS BEFORE APPLYING. TYPE OR PRINT
CLEARLY IN INK.
1. CERTIFICATION TYPE (Check at least one below) Renewal applications should only be submitted
within 90 days prior to the firm’s certification expiration date.)
□ SMALL BUSINESS
□ SMALL BUSINESS-PUBLIC
□ DISABLED VETERAN
(SB)
WORKS (SB-PW)
BUSINESS ENTERPRISE (DVBE)
Owner/officer must sign
Owner/officer must sign Section N
Disabled Veteran qualifier (DV)
Section N
must sign Sections N and O
A. REGISTRATION & CONTACT INFORMATION (ALL APPLICANTS)
2. LEGAL BUSINESS NAME
3. PRIMARY “DOING BUSINESS AS” (DBA)
NAME, IF ANY
4. SECONDARY “DOING BUSINESS AS” (DBA)
NAME, IF ANY
5. FEDERAL EMPLOYER IDENTIFICATION
6. OWNER’S SOCIAL SECURITY NUMBER
NUMBER (FEIN)
(SSN) (Only for sole proprietorships that
do not use a FEIN)
7. OFFICE MAILING ADDRESS
CITY (Required)
STATE
ZIP CODE
COUNTY
(Required)(Street address or P.O. Box)
(Required)
(Required)
Do not leave blank.
CITY (Required)
8. PHYSICAL ADDRESS OF PRINCIPAL
STATE
ZIP CODE
COUNTY
(Required)
(Required)
OFFICE (Required)(Do not use P.O.
Do not leave blank.
Box.)
Do not leave blank.
Page 2
9. BUSINESS PHONE
10. BUSINESS FAX
11. BUSINESS
12. BUSINESS WEB
NUMBER
NUMBER
MOBILE
ADDRESS
NUMBER
13. CONTACT PERSON'S FIRST AND
14. CONTACT PERSON’S
15. CONTACT PERSON’S
LAST NAME
EMAIL ADDRESS
PHONE NUMBER
16. LOGIN USER ID FOR ONLINE ACCESS (MAXIMUM 30 CHARACTERS. IF A USER ID IS NOT
PROVIDED, THE EMAIL ADDRESS FROM SECTION 14 WILL BE USED.)
Do not leave blank.
YES
NO
17. I APPROVE THE SHARING OF MY CERTIFICATION INFORMATION WITH OTHER
GOVERNMENT AND LOCAL AGENCIES FOR THE PURPOSE OF
PARTICIPATING IN THEIR BUSINESS CERTIFICATION PROGRAMS.
YES
NO
18a. SB AND/OR SB-PW ONLY: IS THE APPLICANT FIRM MILITARY VETERAN
OWNED?
YES
NO
18b. SB AND/OR SB-PW ONLY: ANSWER ONLY IF 18 IS 'YES'. IS THE MILITARY
VETERAN OWNERSHIP AT LEAST 51%?
19a. TO REQUEST EXPEDITED PROCESSING, ENTER
19b. BID
19c. CONTRACT
THE BID DUE DATE AND BID NUMBER FOR A BID
DUE DATE
OR BID NUMBER
THAT REQUIRES THIS CERTIFICATION. ATTACH
THE BID SOLICITATION PAGE THAT LISTS THE BID
DUE DATE (BDD).
B. INDUSTRY TYPE (ALL APPLICANTS)
YES
NO
20. DOES THIS FIRM PROVIDE SERVICES?
YES
NO
21a. DOES THIS FIRM HOLD A CONSTRUCTION CONTRACTOR’S LICENSE WITH
THE CONTRACTORS STATE LICENSE BOARD (CSLB)?
21b. IF 21a. IS YES, PROVIDE THE:
21b. CONTRACTOR’S LICENSE NUMBER
21c. LICENSE CLASSIFICATION(S)
YES
NO
22a. DOES THIS FIRM SEL L PRODUCTS AS A RESELLER , DISTRIBUTOR,
WHOLESALER, RETAILER , ETC.?
22b. IF THIS FIRM SELLS PRODUCTS, PROVIDE THE DEPARTMENT OF TAX
AND FEE ADMINISTRATION SELLERS PER MIT NUMBER:
YES
NO
23. DOES MORE THA N 50% O F THIS FIRM’ S ANNUAL GROSS RECEIPTS RES ULT
FROM THE SALE OF PRODUCTS IT MANUFACTURES?
YES
NO
24. DOES THIS FIRM USE ITS OWN FACILITIES TO MANUFACTURE ITS
PRODUCTS?
Page 3
YES
NO
25. DOES THIS FIRM TRANSFO RM ORIGINAL SUBSTANCES O R MATERIALS INTO
A P RODUCT WITH NEW CHA RACTERISTICS?
C. BUSINESS INFORMATION (ALL APPLICANTS)
26a. BUSINESS STRUCTURE TYPE (Check one)
SOLE PROPRIETORSHIP
PARTNERSHIP
LIMITED LIABILITY
PARTNERSHIP (LLP)
JOINT VENTURE
CORPORATION
LIMITED LIABILITY
COMPANY (LLC)
26b. CORPORATIONS & LLCs MUST PROVIDE THEIR CALIFORNIA SECRETARY OF STATE
NUMBER:
27. DATE BUSINESS STARTED
28. MONTH TAX YEAR BEGINS
29a . If thi s firm’s business structure type changed within the most recent three tax years, ente r the
previous type and the date the change occurred below:
29b. PREVIOUS BUSINESS STRUCTURE
29c. DATE OF BUSINESS STRUCTURE TYPE
TYPE
CHANGE
30. IS THIS FIRM A FRANCHISE?
YES
NO
D. AFFILIATE BUSINESS RELATIONSHIPS (SMALL BUSINESS AND/OR SMALL BUSINESS-
PUBLIC WORKS APPLICANTS ONLY)
31a. Answer the eight questions below:
The applicant business, including its owners/officers, or partners, or LLC managers and/or members,
must disclose affiliate business relationship information regardless of the affiliate’s industry. The
following questions will help determine if an affiliate business relationship currently exists or existed
within the previous three tax years. You must answer Yes or No, do not indicate N/A.
For more information on affiliation, click one of the following links:
Affiliate FAQs
(MS Word document)
Affiliate FAQs
(PDF document)
DURING ANY ONE (OR ALL) OF THE PREVIOUS THREE TAX YEARS, DID THE APPLICANT
FIRM AND/OR ITS INDIVIDUAL OWNERS/OFFICERS/PARTNERS/LLC MANAGERS AND/OR
MEMBERS DO ANY OF THE FOLLOWING:
YES NO
1. HAVE A CONTROLLING OWNERSHIP INTEREST IN ANOTHER BUSINESS,
INCLUDING SOLE PROPRIETORSHIPS AND/OR THE PURCHASE OF A
BUSINESS?
YES NO
2. HAVE ANY OWNERSHIP INTEREST IN ANOTHER BUSINESS, INCLUDING THE
PURCHASE OF A BUSINESS?
3. HAVE A ROLE IN MAKING BUSINESS DECISIONS AND MANAGING DAY-TO-
YES NO
DAY OPERATIONS OF ANOTHER BUSINESS?
Page 4
YES NO
4. HAVE A FAMILY MEMBER WHO OWNS A SIMILAR TYPE OF BUSINESS?
YES NO
5. HAVE A FINANCIAL RELATIONSHIP WITH AN INDIVIDUAL OR ANOTHER
BUSINESS, SUCH AS ASSISTING WITH LOANS, BONDING, SECURITY, OR
CREDIT? (Exclude relationships with public financial institutions.)
YES NO
6. HAVE A CONTRACTUAL RELATIONSHIP WITH ANOTHER BUSINESS, SUCH AS
ASSIGNMENTS OR TITLE TRANSFERS?
YES NO
7. SHARE FACILITIES, EQUIPMENT OR SYSTEMS WITH ANOTHER BUSINESS?
8. SHARE EMPLOYEES WITH ANOTHER BUSINESS?
YES NO
31b. If you answered YES to any of the questions in Section 31a, complete the section below.
Only list an affiliate business once. Attach additional paper if necessary.
If a business was affiliated during the previous three tax years, and is no longer affiliated,
disclose the affiliate business and the affiliate business end date in the section below.
Affiliate Business Information
Individual
Affiliate
Affiliate
Affiliate
associated with
Owner
Business
Avg.# of
applicant &
ship %
Start date
Employees
affiliate
End date
during last
4 qtrs. (if
applicable)
Business Name
1
Business Address
Business Name
2
Business Address
Request for Small Business, Small Business-Public Works & DVBE Certification (Application) (Rev. 09/2019)
Page 5
E. DV EQUIPMENT OWNERSHIP (DVBE APPLICANTS ONLY)
Answer the following questions that apply to equipment rental:
YES NO
32a. DOES THIS FIRM RENT EQUIPMENT TO THE STATE?
YES NO
32b. IF 32a IS NO, SKIP THIS QUESTION. IF 32a IS YES, DOES THE DV OWN 51%
OF THE QUANTITY AND VALUE OF EACH PIECE OF EQUIPMENT THAT WILL BE
PROVIDED FOR RENTAL UNDER A CONTRACT?
F. DVBE MANAGERIAL CONTROL (DVBE APPLICANTS ONLY)
Answer the following questions:
YES NO
33. IS THE DV OWNER AND/OR DV MANAGER RESPONSIBLE FOR THE
NEGOTIATIONS, EXECUTION, AND SIGNATURE OF CONTRACTS?
YES NO
34. IS THE DV OWNER AND/OR DV MANAGER RESPONSIBLE FOR THE
EXECUTION (SIGNING) OF FINANCIAL TRANSACTIONS AND AGREEMENTS
(CREDIT, BANKING, BONDING, ETC.)?
G. DVBE OPERATIONAL CONTROL (DVBE APPLICANTS ONLY)
Answer the following questions:
YES NO
35. ARE THERE ANY FORMAL OR INFORMAL RESTRICTIONS LIMITING THE
VOTING POWER OR CONTROL OF THE DV OWNER AND/OR MANAGER?
YES NO
36. ARE THERE ANY THIRD PARTY AGREEMENTS RESTRICTING DV OWNER
AND/OR DV MANAGER CONTROL?
YES NO
37. DOES THE DV OWNER AND/OR DV MANAGER POSSESS THE REQUISITE
EXPERIENCE, EDUCATION, KNOWLEDGE, AND QUALIFICATIONS IN THE
FIRM’S FIELD OF OPERATIONS?
YES NO
38. ARE THE SALARY/PROFITS OF THE DV OWNER AND/OR DV MANAGER
(PROPORTIONATE) WITH THEIR OWNERSHIP INTEREST?
YES NO
39. DOES THE DV OWNER AND/OR DV MANAGER HAVE DIRECT
RESPONSIBILITY FOR SUBORDINATES, IF ANY?
YES NO
40. DOES THE DV OWNER AND/OR DV MANAGER HAVE DIRECT
RESPONSIBILITY FOR SUBCONTRACTORS, IF ANY?
YES NO
41. DOES THE DV OWNER AND/OR DV MANAGER HAVE DIRECT
RESPONSIBILITY FOR THE APPLICANT FIRM’S EQUIPMENT, IF ANY?
YES NO
42. DOES THE DV OWNER AND/OR DV MANAGER HAVE DIRECT
RESPONSIBILITY FOR THE APPLICANT FIRM’S MATERIALS, IF ANY?
YES NO
43. DOES THE DV OWNER AND/OR DV MANAGER HAVE DIRECT
RESPONSIBILITY FOR THE APPLICANT FIRM’S FACILITIES (OFFICE/YARD)?
YES NO
44. IS THE DV OWNER AND/OR DV MANAGER ENGAGED OR EMPLOYED WITH
ANOTHER BUSINESS?
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