(“Minority Business Registered” shall mean a business which is an independent and continuing operation for profit, performing a
commercially useful function, and is owned and controlled by
one or more ethic groups. Business must also be located outside of the City of
Columbus MSA area.)
1. ____________________________________________________________ ________________________________________________
Company Name Federal Tax Id or Social Security Number
2. ____________________________________________________________ _______________________________________________
Type of Business (Corporation, Partnership, Sole Proprietorship) Date company was established
3. Type of Industry, (Please check all that apply): Construction
Professional Services
Goods Miscellaneous
4. Please describe the major activity of the company. Please be specific:
5. _________________________________________________________________________________________________________________
Business Street Address P.O. Box
________________________________________________________, __________________________________ ___________________
City State Zip
6. _________________________________________________ ____________________________ _______________________________
Owner Phone Number Fax Number
_______________________________________________________ ________________________________________________________
(E-mail Address) (Website Address)
7. Ownership Disclosure (Attach additional sheets if necessary):
Owner(s) Name
Minority Designation:
African-American, Women, Hispanic,
Pacific Islander, American
Alaska Natives
8. Is this company DBE Certified? YES NO MBE Certified? YES NO EDGE Certified? YES NO
9. Name of person(s) responsible for day-to-day operation of business. _______________________________________________________
10. Has this company ever conducted business under another name? YES NO
If yes, please state former names (s): _________________________________________________________________________________
11. Are you a U.S. citizen? YES NO If no, do you hold a valid green card? YES NO Please attach a copy of green card.
12. Please attach proof of ethnicity
(Copy Of Birth Certificate Certificate of Naturalization Driver’s Licenses Passport )
13. Please complete the Affidavit. Notarize it and return all information and attachments to ODI.
For Office use only:
Date Received:
Registration Expires: Registered By:
The undersigned swears or affirms that the information submitted in this Certification Application relative to
_____________________________________ (Company Name) is true and further swears or affirms that there has
been no substantive change in ownership and control of this company.
The undersigned further agrees to provide written information relative to any future changes in ownership and/or
management of the company to the City of Columbus Mayor’s Office of Diversity and Inclusion immediately following the
change. The undersigned understands that if the change in information is not submitted, decertification may occur. Any
material misrepresentation of information contained herein will be grounds for decertification.
If the certifying agency determines that substantial evidence is available which indicates the applicant has committed
fraud, appropriate action shall be taken.
(Name, Print)
State of ________________________ County of __________________________________
On this the _______________day of ______________________, 20 _____, before me appeared
(Name) ___________________________________, who affirmed that he or she was properly authorized by
(Name of Company) __________________________to execute the Affidavit and did so as his or her free act
and deed.
(Seal) Notary Public _______________________________ My Commission Expires _______________
Diversity and Inclusion Office
ATTN: Certification Program
1111 East Broad Street
2nd Floor, Suite 203
Columbus, Ohio 43205
Phone (614) 645-4764
Fax (614) 645-6669
Rev. 2019
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