Fillable N.C. DEPARTMENT OF ADMINISTRATION Statewide Uniform Certification Application (North Carolina)

Fill Online, Printable, Fillable, Blank N.C. DEPARTMENT OF ADMINISTRATION Statewide Uniform Certification Application (North Carolina) Form

Use Fill to complete blank online NORTH CAROLINA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

N.C. DEPARTMENT OF ADMINISTRATION Statewide Uniform Certification Application (North Carolina)

On average this form takes 76 minutes to complete

The N.C. DEPARTMENT OF ADMINISTRATION Statewide Uniform Certification Application (North Carolina) form is 5 pages long and contains:

  • 0 signatures
  • 72 check-boxes
  • 270 other fields

Country of origin: US
File type: PDF

BROWSE NORTH CAROLINA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
N.C. DEPARTMENT OF ADMINISTRATION
OFFICE FOR HISTORICALLY UNDERUTILIZED BUSINESSES (HUB OFFICE)
1336 Mail Service Center, Raleigh, NC 27699-1336 ▪ (984) 236-0130 ▪ Fax (919)-807-2335
Website: ncadmin.nc.gov/businesses/hub ▪ Email Address: huboffice.doa@doa.nc.gov
Statewide Uniform Certification Program
Statewide Uniform Certification Application
Thank you for your interest in becoming certified as a HUB firm with the State of North Carolina under the Statewide
Uniform Certification Program (SWUC). Per N.C. General Statute 143-128.4, to qualify as a historically underutilized
business, a business must be at least 51% owned, controlled and managed by one or more citizens or lawful permanent
residence of the United States who are members of one or more of the following groups: (1) Black, (2) Hispanic, (3)
Asian American, (4) American Indian, (5) Female, (6) Disabled and (7) Disadvantaged.
The Office for Historically Underutilized Businesses will request documentation based on your business structure to
determine your eligibility for certification as a historically underutilized business. All applicants are required to submit this
application as part of the required documentation.
To initiate the HUB Certification Process: (1) Complete the SWUC Application (2) Gather required documents based
on your business structure, (3) Complete an online HUB Certification Request by clicking
https://vendor.ncgov.com/vendor/login, then click “Vendor Not Registered. Register Now, Complete the Registration
Process (4) Mail your completed package to the address above.
To initiate HUB Re-Certification or HUB Update: (1) Go to https://vendor.ncgov.com/vendor/login, (2) Enter your User
ID and Password (if you have forgotten ID/Password call NC electronic Vendor Portal Helpdesk at 1-888-211-7440, option
2 or by email at vendor@nc.gov), (3) Click the HUB Certification tab, (4).Complete the "HUB Ownership Information"
(Update any information and change the number of years owned), (5) Click “Next”, (6) Click on "Logout". (7) Applicants
for Re-Certification must complete the SWUC Application for Recertification and (8) submit the required documents based
on your business structure.
Section 1. General Information
Name of Firm
Contact Name
Title
Business Phone #
Cell Phone #
Fax #
Pager #
Website
Email Address
Addresses
Physical (no post office boxes)
Mailing (only if different from physical address)
County
Section 2. Company Information
Firm’s Identification
Legal Name of Firm
Unique Identifier for firm
(Select One)
F
EIN _______________
DUNS
________________
OTHER ______________
Method of Acquisition
Started new business
Bought existing business
Merger or consolidation
Inherited business
Other
Firm’s Profile
Business structure
Corporation (including PLLC)
Limited Liability Company
Partnership (including LLP)
Sole Proprietorship
Joint Venture
.
Date Firm was established
Firm’s Relationship with Other Businesses
Is your firm co-located at any of its business locations with any other business, organization, or entity? If yes, who?
Does your firm, at any of its business locations, share a phone number, P.O. box, office space, yard, warehouse,
facilities, equipment or office staff with any other business, organization, or entity? If yes, who?
Do any of your immediate family members own or manage another company? If yes, explain.
Has any other firm had an ownership interest in your firm at present or at any time in the past?
At present, or at any time in the past, has your firm:
Been a subsidiary of another firm? Y or N
Consisted of a partnership in which one or more of the partners are other firms? Y or N
Owned a percentage of another firm? Y or N
Had any subsidiaries? Y or N
Operated under a franchise agreement? Y or N
Section 3. Ownership Information (Ownership percentages must total 100)
If there are more than two owners, attach a separate sheet.
Owner #1
Name
Title
Contact Phone #
Ethnicity:
Black
Hispanic
Asian American
American Indian
Gender
Male
Female
Disabled
Yes
No
Disadvantaged
Are you a U.S. Citizen or
permanent resident alien of
the U.S.?
Yes
No
Percentage of ownership
Date applicant acquired
ownership
Initial Investment to Acquire Ownership
Cash: $_______________
Real Estate: $ _____________
Equipment: $ ______________
Expertise: $ _______________
# of shares owned
Are you related by blood or marriage to any of the other owners? If yes, who?
Do you own any other businesses?
Do you perform a supervisory or management function for another firm?
Do you work for any company, organization or entity that has a relationship with this firm?
Identify the daily management functions for which you are responsible by placing a check mark in the appropriate
box
below:
Financial Decision making
Office Management
Hiring/Firing of management personnel
Field/Production Operations/Supervisor
Estimating and Bidding
Purchasing of Major Equipment
Marketing / Sales
Negotiating and Contract Execution
Authorized to make Financial Transactions
Authorized to Sign Company Checks (For any
purpose)
Owner #2
Name
Title
Contact Phone #
Ethnicity:
Black
Hispanic
Asian American
American Indian
Gender
Male
Female
Disabled
Yes
No
Disadvantaged
Are you a U.S. Citizen or
permanent resident alien of
the U.S.?
Yes
No
Percentage of ownership
Date applicant acquired
ownership
Initial Investment to Acquire Ownership
Cash: $_______________
Real Estate: $ _____________
Equipment: $ ______________
Expertise: $ _______________
# of shares owned
Are you related by blood or marriage to any of the other owners? If yes, who?
Do you own any other businesses?
Do you perform a supervisory or management function for another firm?
Do you work for any company, organization or entity that has a relationship with this firm?
Identify the daily management functions for which you are responsible by placing a check mark in the appropriate
box below:
Financial Decision making
Office Management
Hiring/Firing of management personnel
Field/Production Operations/Supervisor
Estimating and Bidding
Purchasing of Major Equipment
Marketing / Sales
Negotiating and Contract Execution
Authorized to make Financial Transactions
Authorized to Sign Company Checks (For any
purpose)
List all contributions or transfers of assets to/from your firm and to/from any of its owners over the past two years
(attach additional sheets if needed):
Contribution/Asset
Dollar Value
From Whom
Transferred
To Whom
Transferred
Relationship
Date of
Transfer
1.
2.
3.
Section 4. Control
A. Officers and Board of Directors
Identify your firm’s Officers & Board of Directors (If additional space is required, attach a separate sheet):
Name
Title
Date Appointed
Ethnicity
Gender
1. Officers
of the
Compan
y
(a)
(b)
(c)
(d)
(e)
2. Board of
Directors
(a)
(b)
(c)
(d)
(e)
3. Do any of the persons listed above perform a management or supervisory function for any other business? [ ] Yes [ ] No
If Yes, identify for each: Person: ____________________________ Title: ______________________
Business: ________________________________ Function:
___________________________
4. Do any of the persons listed above own or work for any other firm(s) that has a relationship with this firm (e.g., ownership
interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)? [ ] Yes [ ] No If Yes,
identify for each: Firm Name: ______________________ Person: ________________________
Nature of Business Relationship: _
__________________________________________________________
B. Daily Management Functions)
Identify your firm’s management personnel (non-owners) who control your firm in the following areas (If more than
two persons, attach a separate sheet):
Name
Title
Ethnicity
Gen
der
(1) Financial Decisions (responsibility for
acquisition of lines of credit, surety
bonding, supplies, etc.)
a.
b.
(2) Estimating and bidding
a.
b.
(3) Negotiating and Contract Execution
a.
b.
(4) Hiring/firing of management personnel
a.
b.
(5) Field/Production Operations
Supervisor
a.
b.
(6) Office management
a.
b.
(7) Marketing/Sales
a.
b.
(8) Purchasing of major equipment
a.
b.
(9) Authorized to Sign Company Checks
(for any purpose)
a.
b.
(10) Authorized to make Financial
Transactions
a.
b.
(11) Does your firm rely on any other firm for management functions or employee payroll? [ ] yes [ ] no
If yes, explain.
C. Professional Licenses
List current licenses /permits held by any owner and/or employee of your firm (e.g., contractor, engineer, architect, etc.)
Name of License or Permit
Holder
Type of License/Permit
Expiration
Date
License Number and State
a)
b)
c)
Section 5. References
Please provide two business
references Name: ____________________________
Address:
_______ ______________
____________
___
______________________________
Phone: ___________________________
Name: __________________________
Address:
________________________________
________________________________
Phone:
___________________________
Section 6. Other Certifications
Please check the agencies or certifications currently held by your
firm.
DBE (Any State Departments of Transportation)
What is the date of your most recent site
visit?
_____ / _____/ _____
Performed by (Agency):
___________________________________
Contact Name:
___________________________________
Agency Phone: ( ) _____-_________
SBE 8(a)
Home State Certification
Other (Specify) ___________________________
Section 7. NC Small Business Enterprise Certification (NCSBE)
Please check the box below:
I would like to apply for NC Small Business Enterprise Certification, in addition to HUB Certification.
I understand that the HUB Office may access all publically available information in reviewing my
firm’s application.
____
________________________________ ________________________________________
Signature of Owner Date
N
OTE: TO AVOID DELAY IN PROCESSING YOUR CERTIFICATION, PLEASE CHECK YOUR
APPLICATION AND SUPPORTING DOCUMENTS TO ENSURE ALL REQUIRED
INFORMATION IS INCLUDED.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

N.C. DEPARTMENT OF ADMINISTRATION Statewide Uniform Certification Application (North Carolina)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document