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
U.S. DOT Uniform DBE / ACDBE Certification Application • Page 3 of 15
