Page 14 of 16
PBE ADDENDUM
EFFECTIVE JANUARY 1, 1992, PUBLIC ACT 87-701 ALLOWS FOR BUSINESSES OWNED AND OPERATED BY A
PERSON WITH DISABILITY TO PARTICIPATE IN A PREFERENTIAL PROCUREMENT PROGRAM FOR STATE
GOVERNMENTAL CONTRACTS.
IF YOU WISH TO APPLY UNDER THIS CATEGORY, COMPLETE THE QUESTIONS IN SECTION E.
E. “ BUSINESS OWNED AND OPERATED BY A PERSON WITH A DISABILITY” means a business
concern of which at least 51 percent is owned by one or more persons with a disability, or in the case of
corporation, one in which at least 51 per centum of the stock is owned by one or more persons with a
disability or by a not for profit agency for the disabled organized pursuant to Section 501 of the Internal
Revenue Code of 1954; and the management and daily business operations of which are controlled by
one or more of the persons with a disability who own it.
PERSON WITH A DISABILITY shall mean a person who is a citizen or lawful permanent resident of the
United States and who has a medically diagnosed, severe physical or mental disability that results from
amputation, arthritis, autism, blindness, burn injury, cancer, cerebral palsy, cystic fibrosis, deafness, head
injury, heart disease, hemiplegia, hemophilia, respiratory or pulmonary dysfunction, mental retardation,
mental illness, multiple sclerosis, muscular dystrophy, musculoskeletal disorders, neurological disorders
(including stroke and epilepsy), paraplegia, quadriplegia and other spinal cord conditions, sickle cell
anemia, specific learning disabilities, or end stage renal failure disease; and substantially limits at least one
of the major life activities such as mobility, communication, self-care, self-direction, interpersonal skills, and
work tolerance or work skills in terms of employability; or any other disability or combination of disabilities,
which is determined by an evaluation of rehabilitation potential to cause a comparable degree of
substantial functional limitation similar to the specific list of disabilities, listed above. {language as
specified in P. Act 87-701, Section 2.1, (a) and (b)}.
UNDER THIS DEFINITION, THIS FIRM IS: (CHECK WHERE APPROPRIATE)
A business owned and operated by a person(s) with a disability(s).
IF CHECKED, CONTINUE TO RESPOND, AS APPROPRIATE, TO THE
FOLLOWING DOCUMENTATION:
Owner(s) has been or currently is a Department of Rehabilitation Services
client in the Vocational Rehabilitation program.
Soc. Soc. Number ________________ DHS/ORS Site __________________________
Date of Birth _____________________ Site Telephone Number ___________________
IF CHECKED ABOVE, DO NOT PROCEED
Page 15 of 16
IF NOT CHECKED, FOR EACH OWNER WITH A DISABILITY THE DOCUMENTATION LISTED BELOW MUST
be obtained from a licensed medical physician, which addresses the definition of “disability”.
OWNER’S FULL NAME ______________________________________________
Disability (1)
(2)
(3)
FUNCTIONAL LIMITATION
CHECK ALL APPROPRIATE:
Mobility
Communication
Self-Care
Self-Direction
Interpersonal Skills
Work Tolerance
Work Skills
Other
SIGNATURE OF CERTIFYING PHYSICIAN TELEPHONE NUMBER
PROFESSIONAL MEDICAL LICENSE NUMBER STATE
THIS PAGE MAY BE REPLICATED AS NEEDED.
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome