Fillable Completed MBD Registration Application (Port of Richmond)

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Completed MBD Registration Application (Port of Richmond)

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City of Richmond
Minority Business Development
Registration Checklist
□ Completed MBD Registration Application
□ Copy of Government Issued Photo Identification of the business owner(s);
(e.g. DMV License, Passport, Non-Drivers License) –color copy preferred
□ Copy of Business License
□ Copy of Contractors Business Class License (If Applicable)
□ Proof of Ownership (Copy)
□ Copy of Articles of Incorporation or Articles of Organization
□ Copy of Bond Certification (If Applicable)
□ Work History in Related Business Field (Brochure or Resume)
□ Copy of one of the following Certifications:
Virginia Department of Minority Business Enterprise
o Small, Women and Minority-Owned Business (SWaM)
o Disadvantaged Business Enterprise (DBE)
SBA 8A Certified
VDOT (DBE –Women-Owned)
DBE/Metro Washington Airport Authority (MWAA)
Other Certification(s) (please specify): _______________________________
The first 8 items are needed to register your business with the City of Richmond, Minority Business
Development office. The last item (certifcation) is needed within 180 days of your business
registering with the City of Richmond, Minority Business Development. An incomplete registration
application is kept on file for 180 days from the date the registration is received. After 180 days, your
application with be discarded. Feel free to contact Minority Business Development should you have
questions about the registration process.
Please remember to completely fill out the MBD application.
Failure to do so will delay the processing of your application.
Documents can be mailed, faxed, delivered or emailed to
Minority.Business.Development@richmondgov.com
Minority Business Development
900 E. Broad Street, 16t h Floor, Room 1603 Richmond, VA 23219
Phone: (804)646‐5947 Fax: (804)646‐0136
Minority Business Development
900 East Broad Street
City Hall, 16th Floor, Room 1603
Richmond, VA 23219
Office: (804) 646-5947
Fax: (804) 646-0136
http://www.richmondgov.com/MBD
Minority Business Development Registration
Minority Business means a business at least fifty -one percent of
which is owned and controlled or fifty -one percent minority-owned
and operated by minority group members or, in case of a stock
corporation, at least fifty-one percent of the stock is owned and
controlled by minority group members. Minority group members
are citizens of the U.S who are African -American, Hispanic -
American, Asian-American and American Indian.
Contact Person
Prefix:
First Name:
Last Name:
Company Name:
Primary Company Address:
City:
State:
Phone:
Fax:
E-Mail:
Website:
Principal Owner(s)
NAME
GENDER
RACE/ETHNICITY
MALE FEMALE
BLACK/
AFRICAN
AMERICAN
HISPANIC/
LATINO
AMERICAN
ASIAN
AMERICAN
NATIVE
INDIAN
ANGLO
AMERICAN
MALE FEMALE
BLACK/
AFRICAN
AMERICAN
HISPANIC/
LATINO
AMERICAN
ASIAN
AMERICAN
NATIVE
INDIAN
ANGLO
AMERICAN
MALE FEMALE
BLACK/
AFRICAN
AMERICAN
HISPANIC/
LATINO
AMERICAN
ASIAN
AMERICAN
NATIVE
INDIAN
ANGLO
AMERICAN
FIRM TYPE:
SOLE
PROPRIERTORSHIP
PARTNERSHIP
CORPORATION
(State of INC.)
OTHER (SPECIFY)
BUSINESS TYPE:
DATE BUSINESS COMMENCED:
Fed ID/SSN No.
City:
State:
DESCRIPTION OF
SERVICES
HAS YOUR COMPANY PREVIOUSLY
BEEN DEBARRED FROM DOING BUSINESS WITH
ANY GOVERNMENT ENTITY? IF YES, EXPLAIN
YEARS IN BUSINESS:
BUSINESS LICENSE JURISDICTION : N/A
POSSES ALL STATE/CITY LICENSES TO LEGALLY
CONDUCT BUSINESS IN VA
YES NO
WORK
FORCE
SIZE
CONTRACTOR’S LICENSE :
A B C N/A
CURRENTLY INSURED
IF YES TO WHAT AMOUNT?
YES NO $
CURRENTLY BONDED
IF YES, TO WHAT AMOUNT?
YES NO $
TYPE OF CERTIFICATION (EXAMPLE: MBE, DBE, WBE, ETC.)
All f irm s listed in M BD dir ectory have regist ered w ith the C ity of
Richm ond as a minority own ed business (MBE) or cert if ied as an
Emerging Small Bu siness (ESB) . It sho uld be noted, that the re
are M BE bu sinesses listed in this direct ory t hat are not
certifi ed. Ther efore, an y prime contractor/ve ndor desiring to
use a regi ster ed MBE firm that is not c ertified, must be aware,
that the register ed MBE firm ha s 180 days to get certif ied or
before t he comp leti on of the contract , which ever is less, or the
prime contract or/vendor r isk s not rec eiving credit t oward t he
minor ity part icip ation goal f or the s aid project.
CERTIFICATION SOURCE (EXAMPLE: VA DEPT. OF TRANSPORTATION, VA
DEPT. OF MINORITY BUSINESS ENTERPRISE, US SMALL BUSINESS
ADMINISTRATION)
YOUR SIGNATURE INDICATES THAT THE ABOVE INFORMATION IS ACCURATE TO THE BEST OF YOUR KNOWLEDGE.
SIGNATURE: TITLE: DATE:
MBE/ESB – 7 MBD Registra tion F orm – Revised Date 1/1/2013
Registration can be faxed, mailed or emailed to
Minority.Business.Development@richmondgov.com
MBE/ESB – 7 MBD Registration Form – Revised Date 3/28/2015
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Completed MBD Registration Application (Port of Richmond)

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Completed 29 July 2020

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