MISSOURI REGIONAL CERTIFICATION COMMITTEE
NOTICE OF VOLUNTARY WITHDRAWAL
SECTION 1: DISADVANTAGED OWNER(S) INFORMATION
FIRST NAME
MI
LAST NAME
PHONE
EMAIL ADDRESS
1
2
3
4
SECTION 2: FIRM INFORMATION
FIRM NAME
CITY
STATE
ZIP
SECTION 3: VOLUNTARY WITHDRAWAL STATEMENT
After careful consideration, I, the undersigned disadvantaged business enterprise (DBE) owner or
authorized designee, have elected not to apply or continue the firm’s participation as a DBE at this
time. This notice serves to inform the
of this decision.
Mark the explanation that best describes your reason for voluntarily withdrawing the firm from the
DBE/ACDBE program:
Comments: (Text limited for accurate printing.)
SECTION 4: SIGNATURES
DBE APPLICANT (Print Name)
DBE APPLICANT SIGNATURE
DATE
State of:
I certify that this is a true and correct copy of a document in the possession of
Acknowledged before me Day of
, 20
Your name: Notary Public:
My commission expires:
Whoever knowingly makes false statments or false representation as to a material fact in any statement, certificate, or
report submitted pursuant to the provisions of the Federal-Aid road Act approved July 11, 1916 (389. 355) as
amended and supplemented, shall be fined under this title or imprisoned not more than five years or both.
Personal
Net Worth exceeds $1.32 million
Change of firm’s ownership
Sale of business
Business dissolved
No benefit in being certified MRCC, DBE/ACDBE
Not interested in continuing participation in the
DBE/ACDBE program
Other (Provide brief explanation in comments section below)
Rev. 04/2018
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