U.S. DOT Uniform DBE / ACDBE Certification Application Page 1 of 15
OMB APPROVAL NO:
2105-0510
Expiration Date: 10/31/2021
Appendix F
UNIFORM CERTIFICATION APPLICATION
DISADVANTAGED BUSINESS ENTERPRISE (DBE) /
AIRPORT CONCESSION DISADVANTAGED BUSINESS ENTERPRISE (ACDBE)
49 C.F.R. Parts 23 and 26
Roadmap for Applicants
1. Should I apply?
You may be eligible to participate in the DBE/ACDBE program if:
The firm is a for-profit business that performs or seeks to perform transportation related work (or a concession
activity) for a recipient of Federal Transit Administration, Federal Highway Administration, or Federal Aviation
Administration funds.
The firm is at least 51% owned by a socially and economically disadvantaged individual(s) who also controls it.
The firm’s disadvantaged owners are U.S. citizens or lawfully admitted permanent residents of the U.S.
The firm meets the Small Business Administration’s size standard and does not exceed $23.98 million in gross
annual receipts for DBE ($56.42 million for ACDBEs). (Other size standards apply for ACDBE that are
banks/financial institutions, car rental companies, pay telephone firms, and automobile dealers.)
2. How do I apply?
First time applicants for DBE certification must complete and submit this certification application and related material
to the certifying agency in your home state and participate in an on-site interview conducted by that agency. The
attached document checklist can help you locate the items you need to submit to the agency with your completed
application. If you fail to submit the required documents, your application may be delayed and/or denied. Firms
already certified as a DBE do not have to complete this form, but may be asked by certifying agencies outside of your
home state to provide a copy of your initial application form, supporting documents, and any other information you
submitted to your home state to obtain certification or to any other state related to your certification.
3. Where can I send my application? [INSERT UCP PARTICIPATING MEMBER CONTACT INFORMATION]
4. Who will contact me about my application and what are the eligibility standards? A transportation agency in
your state that performs certification functions will contact you. The agency is a member of a statewide Unified
Certification Program (UCP), which is required by the U.S. Department of Transportation. The UCP is a one-stop
certification program that eliminates the need for your firm to obtain certification from multiple certifying agencies
within your state. The UCP is responsible for certifying firms and maintaining a database of certified DBEs and
ACDBEs, pursuant to the eligibility standards found in 49 C.F.R. Parts 23 and 26.
5. Where can I find more information?
U.S. DOThttps://www.transportation.gov/civil-rights
(This site provides useful links to the rules and regulations
governing the DBE/ACDBE program, questions and answers, and other pertinent information)
SBASmall Business Size Standards matched to the North American Industry Classification System (NAICS):
http://www.census.gov/eos/www/naics/ and http://www.sba.gov/content/table-small-business-size-standards.
In collecting the information requested by this form, the Department of Transportation (Department) complies with the provisions of the Federal
Freedom of Information and Privacy Acts (5 U.S.C. 552 and 552a). The Privacy Act provides comprehensive protections for your personal
information. This includes how information is collected, used, disclosed, stored, and discarded. Your information will not be disclosed to third
parties without your consent. The information collected will be used solely to determine your firm's eligibility to participate in the Department's
Disadvantaged Business Enterprise Program as defined in 49 C.F.R. §26.5 and the Airport Concession Disadvantaged Business Enterprise Program
as defined in 49 C.F.R. §23.3. You may review DOT’s complete Privacy Act Statement in the Federal Register published on April 11, 2000 (65 FR
19477).
Under 49 C.F.R. §26.107,
dated February 2, 1999 and January 28, 2011, if at any time, t he Department or a recipient has reason to believe that any
person or firm has willfully and knowingly provided incorrect information or made false statements, the Department may initiate suspension or
debarment proceedings against the person or firm under 2 C.F.R. Parts 180 and 1200
, No procurement Suspension and Department, take
enforcement action under 49 C.F.R. Part 31, Program Fraud and Civil Remedies, and/or refer the matter to the Department of Justice for criminal
prosecution under 18 U.S.C. 1001, which prohibits false statements in Federal programs.
U.S. DOT Uniform DBE / ACDBE Certification Application Page 2 of 15
INSTRUCTIONS FOR COMPLETING THE
DISADVANTAGED BUSINESS ENTERPRISE (DBE)
AIRPORT CONCESSIONS DISADVANTAGED BUSINESS ENTERPRISE (ACDBE)
UNIFORM CERTIFICATION APPLICATION
NOTE: All participating firms must be for-profit enterprises. If your firm is not for profit, then you do NOT qualify for
the DBE/ACDBE program and should not complete this application. If you require additional space for any question in
this application, please attach additional sheets or copies as needed, taking care to indicate on each attached sheet/copy
the section and number of this application to which it refers.
Section 1: CERTIFICATION INFORMATION
A. Basic Contact Information
(1) Enter the contact name and title of the person
completing this application and the person who will
serve as your firm's contact for this application.
(2) Enter the legal name of your firm, as indicated in your
firms Articles of Incorporation or charter.
(3) Enter the primary phone number of your firm.
(4) Enter a secondary phone number, if any.
(5) Enter your firms fax number, if any.
(6) Enter the contact person's email address.
(7) Enter your firms website addresses, if any.
(8) Enter the street address of the firm where its offices are
physically located (not a P.O. Box).
(9) Enter the mailing address of your firm, if it is different
from your firm’s street address.
B. Prior/Other Certifications and Applications
(10) Check the appropriate box indicating whether your firm
is currently certified in the DBE/ACDBE programs,
and provide the name of the certifying agency that
certified your firm. List the dates of any site visits
conducted by your home state and any other states or
UCP members. Also provide the names of state/UCP
members that conducted the review.
(11) Indicate whether your firm or any firms owned by the
persons listed has ever been denied certification as a
DBE/ACDBE, 8(a), or Small Disadvantaged Business
(SDB) firm, or state and local MBE/WBE firm. Indicate
if the firm has ever been decertified from one of these
programs. Indicate if the application was withdrawn or
whether the firm was debarred, suspended, or otherwise
had its bidding privileges denied or restricted by any
state or local agency, or Federal entity. If your answer
is yes, identify the name of the agency, and explain
fully the nature of the action in the space provided.
Indicate if you have ever appealed this decision to the
Department and if so, attach a copy of USDOT’s final
agency decision(s).
Section 2: GENERAL INFORMATION
A. Business profile:
(1) Give a concise description of the firm’s primary
activities, the product(s) or services the company
provides, or type of construction. If your company
offers more than one product/service, list primary
product or service first (attach additional sheets if
necessary). This description may be used in our UCP
online directory if you are certified as a DBE.
(2) If you know the appropriate NAICS Code for the line(s)
of work you identified in your business profile, enter
the codes in the space provided.
(3) State the date on which your firm was established as
stated in your firm’s Articles of Incorporation or
charter.
(4) State the date each person became a firm owner.
(5) Check the appropriate box describing the manner in
which you and each other owner acquired ownership of
your firm. If you checked “Other,” explain in the space
provided.
(6) Check the appropriate box that indicates whether your
firm is “for profit.” If you checked “No,” then you do
NOT qualify for the DBE/ACDBE program and
should not complete this application. All participating
firms must be for-profit enterprises. Provide the Federal
Tax ID number as stated on your firm’s Federal tax
return.
(7) Check the appropriate box that describes the type of
legal business structure of your firm, as indicated in
your firm’s Articles of Incorporation or similar
document. If you checked “Other,” briefly explain in
the space provided.
(8) Indicate in the spaces provided how many employees
your firm has, specifying the number of employees who
work on a full-time, part-time, and seasonal basis.
Attach a list of employees, their job titles, and dates of
employment, to your application.
(9) Specify the firm’s gross receipts for each of the past
three years, as stated in your firm’s filed Federal tax
returns. You must submit complete copies of the firm’s
Federal tax returns for each year. If there are any
affiliates or subsidiaries of the applicant firm or owners,
you must provide these firms’ gross receipts and submit
complete copies of these firm(s) Federal tax returns.
Affiliation is defined in 49 C.F.R. §26.5 and 13 C.F.R.
Part 121.
B. Relationships and Dealings with Other Businesses
(1) Check the appropriate box that indicates whether your
firm is co-located at any of its business locations, or
whether your firm shares a telephone number(s), a post
office box, any office space, a yard, warehouse, other
facilities, any equipment, financing, or any office staff
and/or employees with any other business, organization
or entity of any kind. If you answered “Yes,” then
specify the name of the other firm(s) and fully explain
the nature of your relationship with these other
businesses by identifying the business or person with
whom you have any formal, informal, written, or oral
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
and gender and percentage ownership if any. Circle the
frequency of each person’s involvement as follows:
“always, frequently, seldom, or never” in each area.
Indicate whether any of the persons listed in this section
perform a management or supervisory function for any other
business. Identify the person, business, and their
title/function. Identify if 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
investment, equipment, leases, personnel sharing, etc.) If
you answered “Yes,” describe the nature of his/her business
relationship with that other firm.
C. Inventory: Indicate firm inventory in these categories:
(1) Equipment and Vehicles
State the make and model, and current dollar value of
each piece of equipment and motor vehicle held and/or
used by your firm. Indicate whether each piece is either
owned or leased by your firm or owner, whether it is
used as collateral, and where this item is stored.
(2) Office Space
State the street address of each office space held and/or
used by your firm. Indicate whether your firm or owner
owns or leases the office space and the current dollar
value of that property or its lease.
(3) Storage Space
State the street address of each storage space held
and/or used by your firm. Indicate whether your firm or
owner owns or leases the storage space and the current
dollar value of that property or its lease. Provide a
signed lease agreement for each property.
D. Does your firm rely on any other firm for
management functions or employee payroll?
Check the appropriate box that indicates whether your firm
relies on any other firm for management functions or for
employee payroll. If you answered “Yes,” you may be asked
to explain the nature of that reliance and the extent to which
the other firm carries out such functions.
E. Financial / Banking Information
State the name, City and State of your firm’s bank. Identify
the persons able to sign checks on this account. Provide bank
authorization and signature cards.
Bonding Information. State your firm’s bonding limits both
aggregate and project limits.
F. Sources, amounts, and purposes of money loaned to
your firm, including the names of persons or firms
guaranteeing the loan.
State the name and address of each source, the name of
person securing the loan, original dollar amount and the
current balance of each loan, and the purpose for which each
loan was made to your firm. Provide copies of signed loan
agreements and security agreements
G. Contributions or transfers of assets to/from your firm
and to/from any of its owners or another individual over
the past two years:
Indicate in the spaces provided, the type of contribution or
asset that was transferred, its current dollar value, the person
or firm from whom it was transferred, the person or firm to
whom it was transferred, the relationship between the two
persons and/or firms, and the date of the transfer.
H. Current licenses/permits held by any owner or
employee of your firm.
List the name of each person in your firm who holds a
professional license or permit, the type of permit or license,
the expiration date of the permit or license, and issuing State
of the license or permit. Attach copies of licenses, license
renewal forms, permits, and haul authority forms.
I. Largest contracts completed by your firm in the past
three years, if any.
List the name of each owner or contractor for each contract,
the name and location of the projects under each contract,
the type of work performed on each contract, and the dollar
value of each contract.
J. Largest active jobs on which your firm is currently
working.
For each active job listed, state the name of the prime
contractor and the project number, the location, the type of
work performed, the project start date, the anticipated
completion date, and the dollar value of the contract.
Section 5: AIRPORT CONCESSION (ACDBE)
APPLICANTS
Complete the entries in this section if you are applying for
ACDBE certification. Indicate in Section A if you operate a
concession at the airport, and/or supply a good or service to
an airport concessionaire. Indicate in Section B whether the
applicant firm owns or operates any off-airport locations,
providing the type of business, lease information,
address/location, and annual gross receipts generated.
Provide similar information in section C for any airport
concession locations the firm currently owns or operates. If
the applicant firm has any affiliates, provide the requested
information in Section D. Indicate whether the ACDBE firm
is participating in any joint ventures, and if so, include the
original and any amended joint venture agreements.
AFFIDAVIT & SIGNATURE
The Affidavit of Certification must accompany your
application. Carefully read the attached affidavit in its
entirety. Fill in the required information for each blank
space, and sign and date the affidavit in the presence of a
Notary Public, who must then notarize the form.
U.S. DOT Uniform DBE / ACDBE Certification Application Page 4 of 15
____________________
_____________________
_____________________________________________
________________________________________
___________________________________
( (____) _____ (_
_________________________________
_________________________________
________________ ___________________ ______ ________ - ____
________________ ___________________ ______ ________ - ____
___) ______
-
_____
-
_____ ___ _____ _______ -
)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Section 1: CERTIFICATION INFORMATION
A. Basic Contact Information I am applying
for certification as DBE ACDBE
(1)
Contact person and Title:
(2) Legal name of firm: _________________________
(3) Phone #: (4) Other Phone #: (5) Fax #:
(6) E-mail: (7) Firm Websites:
(8) Street address of firm (No P.O. Box):
City: County/Parish: State: Zip:
(9) Mailing address of firm (if different):
City: County/Parish: State: Zip:
B. Prior/Other Certifications and Applications
(10) Is your firm currently certified for any of the following U.S. DOT programs?
DBE ACDBE Names of certifying agencies: _________________________________________________
If you are certified in your home state as a DBE/ACDBE, you do not have to complete this application for other states.
Ask your state UCP about the interstate certification process.
List the dates of any site visits conducted by your home state and any other states or UCP members:
Date
___/ ___/___ State/UCP Member: ____________ Date ___/ ___/___ State/UCP Member: _______________
(11) Indicate whether the firm or any persons listed in this application have ever been:
(a) Denied certification or decertified as a DBE, ACDBE, 8(a), SDB, MBE/
WBE firm?
Yes No
(b) Withdrawn an application for these programs, or debarred or suspended or otherwise had bidding privileges
denied or restricted by any state or local agency, or Federal entity?
Yes No
If yes, explain the nature of the action. (If you appealed the decision to DOT or another agency
, attach a copy of the decision)
Section 2: GENERAL INFORMATION
A. Business Profile: (1) Give a concise description of the firm’s primary activities and the product(s) or service(s)
it provides. If your company offers more than one product/service, list the primary product or service first. Please
use additional paper if necessary. This description may be used in our database and the UCP online directory if you
are certified as a DBE or ACDBE.
(2) Applicable NAICS Codes for this line of work include:
______ ______ _______ _______ ________ ______
(3) This firm was established on
_
___/____/____
(4) I/We have owned this firm since:
____/____/____
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_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________________________
__________________________________________
________ ________ ________ _________
_______ _____________ __________
_______ ______________ _________
_______ _____________ __________
____________________________________________________________________
(5) Method of acquisition (Check
all that apply):
Started new business Bought existing business Inherited business Gifted
Merger or consolidation Other (explain)
(6) Is your firm “for profit”? Yes
Federal Tax ID#
________________________
No→ STOP! If your firm is NOT for-profit, then you do NOT
qualify for this program and should not fill out this application.
Sole Proprietorship
Limited Liability Partnership
Partnership Corporation
Limited Liability Company Other, Describe
Full-time Part-time Seasonal Total
(Provide a list of employees, their job titles, and dates of employment, to your application).
each year. If there are affiliates or subsidiaries of the applicant firm or owners, you must submit complete copies of these
firms’ Federal tax returns).
Year Gross Receipts of Applicant Firm $ Gross Receipts of Affiliate Firms $
Year Gross Receipts of Applicant Firm $ Gross Receipts of Affiliate Firms $
Year Gross Receipts of Applicant Firm $ Gross Receipts of Affiliate Firms $
B. Relationships and Dealings with Other Businesses
(1) Is your firm co-located at any of its business locations, or does it share a telephone number, P.O. Box, office
or storage space, yard, warehouse, facilities, equipment, inventory, financing, office staff, and/or employees with
any other business, organization, or entity? Yes No
If Yes, explain the nature of your relationship with these other businesses by identifying the business or person with whom you
have any formal, informal, written, or oral agreement. Also detail the items shared
Yes No If Yes, explain
(3) At present, or at any time in the past, has your firm:
(a) Ever existed under different ownership, a different type of ownership, or a different name? Yes No
(b) Existed as a subsidiary of any other firm? Yes No
(c) Existed as a partnership in which one or more of the partners are/were other firms? Yes No
(d) Owned any percentage of any other firm? Yes No
(e) Had any subsidiaries?
Yes No
(f) Served as a subcontractor with another f
irm constituting more than 25% of your firm’s receipts? Yes No
(If you answered “Yes” to any of the questions in (2) and/or (3)(a)-(f), you may be asked to provide further details and explain
whether the arrangement continues).
U.S. DOT Uniform DBE / ACDBE Certification Application Page 6 of 15
Section 3: MAJORITY OWNER INFORMATION
A. Ide
ntify th
e majority owner of the firm holding 51% or more ownership interest.
(1) Full Name:
(2) Title:
(3) Home Phone #:
(4) Home Address (S
treet and Number)
:
City:
State:
Zip:
(5) Gender: Male Female
(6) Ethnic group membership
(Check all that apply):
Black
Hispanic
Asian Pacific
Native American
Subcontinent Asian
Other
(specify)
(7) U.S. Citizenship: U.S. Citizen
Lawfully
Admitted Permanent Resi
dent
(8) Number of years as owner:
%
Date acquired __________
(
10) Initi
al investment to
acquire ownership
interest in firm:
Type Dollar Value
Cash $
Real Estate $
_
Equipment $
Other $
Describe how you acquired your business:
Started business myself.
It was a gift from:
I bought it from:
I inherit
ed it from:
Other
(Attach documentation substantiating your investment)
B. Additional Owner Information
No
If Yes, identify:
Name of Business: Function/Title:
(e.g., ownership
interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.) Yes No
Identify the name of the business, and the nature of the relationship, and the owner’s function at the firm:
than 10 hours per week? If yes, identify this activity:
(4)(a) What is the personal net worth of this disadvantaged owner applying for certification? $
(b)Has any trust been created for the benefit of this disadvantaged owner(s)? Yes No
(If Yes, you may be asked to provide a copy of the trust instrument).
(5) Do any of your immediate family members, managers, or employees own, manage, or are associated with
another company? Yes No If Yes, provide their name, relationship, company, type of business, and
indicate whether they own or manage the company:
(Please attach extra sheets, if needed):
U.S. DOT Uniform DBE / ACDBE Certification Application Page 7 of 15
______________________________ _________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
( ) _____ - ____________________
_____________________________________________________
____________________ ________ _________ - ______
___________________
_______
__________
_________
(9) Percentage
owned:
Class of stock owned:
_________
________
_________
_________
____________________________
_____________________________
____________________________
______________________________________
__________________________________ _______________________________
___________________________________________
____________
______________________
U.S. DOT Uniform DBE / ACDBE Certification Application Page 8 of 15
______________________________ _________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
___________________________________________________________________________________________
( ) _____ - __________________
_____________________________________________________
____________________ ________ _________ - ______
_______
_________
________
___________________
_________
_________
_________
_________
___________________________
____________________________
___________________________
_____________________________________
__________________________________ _______________________________
__________________________________________
____________
_________________
Section 3: OWNER INFORMATION, Cont’d.
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the
firm
(Attach separate sheets for each additional owner)
(1) Full Name: (2) Title:
(3) Home Phone #:
(4) Home Address (Street and Number):
City: State: Zip:
(5) Gender: Male Female
(6) Ethnic group membership
(Check all that apply)
Black
Hispanic
Asian Pacific
Native American
Subcontinent Asian
Ot
he
r
(specify)
(7) U.S. Citizenship:
U.S. Citizen
Lawfully Admitted Permanent Resident
(8) Number of years as owner:
%
Date acquired __________
(9) Percentage
owned:
Class of stock owned:
(10) Initial investment
to acquire ownership
interest in firm:
Type Dollar Val
ue
Cash $
Real Estate $
Equipment $
Other $
Describe how
you acquired your
business:
Started business myself.
It was a gift from:
I bought it from:
I inherited it from:
Other
(Attach documentation substantiating your investment)
B. Additional Owner Information
(1) Describe familial relationship to other owners and employees:
(2) Does this owner perform a management or su
pervisory function for any other business? Yes No
If Yes, identify:
Name of Business: Function/Title:
(3)(a) Does this owner 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
Identify the name of the business, and the nature of the relationship, and t
he owner’s function at the firm:
(b) Does this owner work for any other firm, non-profit organization, or is e
ngaged in any other activity
more than 10 hours per week? If yes, identify this activity:
(4)(a) What is the personal
net worth of this disadvantaged owner applying for certification? $
(b) Has any trust been created for the benefit of this disadvantaged ow
ner(s)? Yes No
(If Yes, you may be asked to provide a copy of the trust instrument).
(5) Do any of your immediate family members, managers, or employees own, manage, or are associated
with another company? Yes No If Yes, provide their name, relationship, company, type of
business, and indicate whether they own or manage: (Please attach extra sheets, if needed):
U.S. DOT Uniform DBE / ACDBE Certification Application Page 9 of 15
__________________________________ _________________________________________________
________________________________ ______________________________________________
__________________________________
_____________________________
_________________________________________________
___ ______________________________________________
_______________________________ ____________________________________________________
__________________________________________________________________________
_______________________
________________________
______
____________________________
_____________________________
_______
Section 4: CONTROL
A. Identify your firm’s O
fficers and Board of Directors (If additional space is required, attach a separate sheet):
Name
Title
Date
Appointed
Ethnicity
Gender
(1) Officers of the Company
(a)
(b)
(c)
(d)
(2) Board of Directors
(a)
(b)
(c)
(d)
(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:
Person: Title:
Business: Function:
(4) Do any of the persons listed in section A 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. Duties o f Owners, Officers, Directors, Managers, and Key Personnel
1. Complete for all Owners who are responsible for the following functions of the firm
(Attach separate sheets as
needed).
A= Always
F = Frequently
S = Seldom
N = Never
Majority Owner (51% or more)
Name:
Ti
tle:
Percent Owned:_
Minority Owner (49% or less)
Name:
T
itle:
Perce
nt Owned:
Sets policy for company direction/scope
of operations
A
F
S
N
A
F
S
N
Bidding and estimating
A
F
S
N
A
F
S
N
Major purchasing decisions
A
F
S
N
A
F
S
N
Marketing and sales
A
F
S
N
A
F
S
N
Supervises field operations
A
F
S
N
A
F
S
N
Attend bid opening and lettings
A
F
S
N
A
F
S
N
Perform office management (billing,
accounts receivable/payable, etc.)
A
F
S
N
A
F
S
N
Hires and fires management staff
A
F
S
N
A
F
S
N
Hire and fire field staff or crew
A
F
S
N
A
F
S
N
Designates profits spending or investment
A
F
S
N
A
F
S
N
Obligates business by contract/credit
A
F
S
N
A
F
S
N
Purchase equipment
A
F
S
N
A
F
S
N
Signs business checks
A
F
S
N
A
F
S
N
U.S. DOT Uniform DBE / ACDBE Certification Application Page 10 of 15
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____________________________________________________________________________________________
________________________
_________________________
_______________
_________________
________________________
_________________________
_______________
_________________
2.
Complete for all Officers, Directors, Managers, and Key Personnel who are responsible for the following
functions of the firm.
(Attach separate sheets as needed).
A= Always
F = Frequently
S = Seldom
N = Never
Officer/Director/Manager/Key Personnel
Name:
Title:
Race and G
ender:
Percent Owned:
Officer/Director/Manager/ Key Personnel
Name:
Title:
Race and
Gender:
Percent Owned:
Sets policy for company direction/scope
of operations
A
F
S
N
A
F
S
N
Bidding and estimating
A
F
S
N
A
F
S
N
Major purchasing decisions
A
F
S
N
A
F
S
N
Marketing and sales
A
F
S
N
A
F
S
N
Supervises field operations
A
F
S
N
A
F
S
N
Attend bid opening and lettings
A
F
S
N
A
F
S
N
Perform office management (billing,
accounts receivable/payable, etc.)
A
F
S
N
A
F
S
N
Hires and fires management staff
A
F
S
N
A
F
S
N
Hire and fire field staff or crew
A
F
S
N
A
F
S
N
Designates profits spending or investment
A
F
S
N
A
F
S
N
Obligates business by contract/credit
A
F
S
N
A
F
S
N
Purchase equipment
A
F
S
N
A
F
S
N
Signs business checks
A
F
S
N
A
F
S
N
Do any of the persons listed in B1 or B2 perform a management or supervisory function for any other business? If Yes,
identify the person, the business, and their title/function:
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.
) If Yes, describe the nature of
the business relationship:
C. Inventory: Indicate your firm’s inventory in the foll
owing categories
(Please attach additional sheets if needed):=
1. Equipment and Vehicles
Make and Model Current
Value
Owned or L
eased
by Firm or Owner?
Used as collateral? Where is item stored?
2. Office Space
Street Address Owned or Leased by Firm or Owner? Current Value
of Property or Lease
_________________________________ _________________________________
______________________________________
_________________________________ _________________________________
______________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________
__________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
3.
Storage Space
(Provide signed lease agreements for the properties listed)
Street Address
Owned or Leased by
Firm or Owner?
Current Value of Property or Lease
D. Does your firm rely on any other firm for management functions or employee payroll? Yes No
E. Financial/Banking Information (Provide bank authorization and signature cards)
Name of bank: City and State:
The following individuals are able to sign checks on this account:
Name of bank: Ci
ty and State:
The following individuals are able to sign checks on this account:
Bonding Inform
ation: If you have bonding capacity, identify the firm’s bonding aggregate and project limits:
Aggregate limit $ Project limit $
F. Identify all sources, amounts, and purposes of money loaned to your firm includi
ng from financial
institutions. Identify whether you the owner and any other person or firm loaned money to the applicant
DBE/ACDBE. Include the names of any persons or firms guaranteeing the loan, if other than the listed owner.
(Provide copies of signed loan agreements and security agreements).
Name of Source Address of Sour
ce Name of Person
Guaranteeing the
Loan
Original
Amount
Current
Balan
ce
Purpose of Loan
1.
2.
3.
G. List all contributions or transfers of assets to/from your firm and to/from any of its owners or another
individual over th
e 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.
H. List current licenses/permits held by any owner and/or employee of your firm
(e.g. contractor, engineer, architect, etc.)(Attach additional sheets if needed):
Name of License/Permit Holder Type of License/Permit Expiration Date State
1.
2.
3.
U.S. DOT Uniform DBE / ACDBE Certification Application Page 11 of 15
U.S. DOT Uniform DBE / ACDBE Certification Application Page 12 of 15
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_______________________________________________________________________________________________
_______________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I. List the three largest contracts completed by your firm in the past three years, if any:
Name of
Owner/Contractor
Name/Location of
Proje
ct
Type of Work Performed Dollar Value of
Contract
1.
2.
3.
J. List the three largest active jobs on which your firm is currently working:
Na
me of Prime
Cont
ractor and Project
Number
Location of
Project
Type of Work Project
Start Date
Anticipated
Completion
Date
Dollar Value
of Contract
1.
2.
3.
Additional Information:
SECTION 5 - AIRPORT CONCESSION
(ACDBE APPLICANTS ONLY)
A. I am applying for ACDBE certification to: (check all that apply)
Operate a concession at an airport Supply a good or service to an airport concessionaire
B. Does the applicant firm own/operate any off-airport locati
ons? Yes No If Yes, identify the following
Type of Business
(e.g., F&B, News & Gift, Retail,
Duty Free, Advertising, etc.)
Lease
Term
(years)
Lease
Start
Date
Address / Location
Annual Gross
Receipts Generated
C. Does the applicant firm currently own/operate any airport concession locations? Yes No If Yes, supply
the following information:
Airport Name Concession Type
(e.g., F&B, News &
Gift, Retail, Duty Free,
Advertising, etc.)
Number of
Leases
Number of
Locations
Annual Gross
Receipts
Generated
Lease Type
(e.g. Direct Lease, Subcontract
Management Agreement, etc. enter
all that apply to the leases listed)
D. Does the applicant firm have any affiliates? Yes No If Yes, provide the following information concerning
any locations owned/operated by affiliate firms.
Airport Name Concession Type
(e.g., F&B, News &
Gift, Retail, Duty Free,
Advertising, etc.)
Number of
Leases
Number of
Locations
Annual Gross
Receipts
Generated
Lease Type
(e.g. Direct Lease, Subcontract
Management Agreement, etc. enter
all that apply to the leases listed)
E. Is the ACDBE applicant firm a participant in any joint ventures? Yes No If Yes, attach all original and
any amended Join
t Venture Agreements and any amendments to the agreements.
U.S. DOT Uniform DBE / ACDBE Certification Application Page 13 of 15
____________________________________________
____________
____________________
___________________________
__________________________________________
_______________________ __________
AFFIDAVIT OF CERTIFICATION
This form must be signed and notarized for each owner upon which disadvantaged status is relied.
A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS
SUFF
ICIENT CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL, INITIATION
OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY
MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES AVAILABLE
PURSUANT TO APPLICABLE FEDERAL AND STATE LAW.
I (full name printed),
swear or affirm under penalty of law that I am
(title) of the applicant firm
and that I
have read and understood all of the questions in this
application and that all of the foregoing information and
statements submitted in this application and its attachments
and supporting documents are true and correct to the best of
my knowledge, and that all responses to the questions are full
and complete, omitting no material information. The responses
include all material information necessary to fully and
accurately identify and explain the operations, capabilities and
pertinent history of the named firm as well as the ownership,
control, and affiliations thereof.
I recognize that the information submitted in this application is
for the purpose of inducing certification approval by a
government agency. I understand that a government agency
may, by means it deems appropriate, determine the accuracy
and truth of the statements in the application, and I authorize
such agency to contact any entity named in the application, and
the named firm’s bonding companies, banking institutions,
credit agencies, contractors, clients, and other certifying
agencies for the purpose of verifying the information supplied
and determining the named firm’s eligibility.
I agree to submit to government audit, examination and review
of books, records, documents and files, in whatever form they
exist, of the named firm and its affiliates, inspection of its
places(s) of business and equipment, and to permit interviews
of its principals, agents, and employees. I understand that
refusal to permit such inquiries shall be grounds for denial of
certification.
If awarded a contract, subcontract, concession lease or
sublease, I agree to promptly and directly provide the prime
contractor, if any, and the Department, recipient agency, or
federal funding agency on an ongoing basis, current, complete
and accurate information regarding (1) work performed on the
project; (2) payments; and (3) proposed changes, if any, to the
foregoing arrangements.
I agree to provide written notice to the recipient agency or
Unified Certification Program of any material change in the
information contained in the original application within 30
calendar days of such change (e.g., ownership changes,
address/telephone number, personal net worth exceeding $1.32
million, etc.).
I acknowledge and agree that any misrepresentations in this
application or in records pertaining to a contract or subcontract
will be grounds for terminating any contract or subcontract
which may be awarded; denial or revocation of certification;
suspension and debarment; and for initiating action under
federal and/or state law concerning false statement, fraud or
other applicable offenses.
I certify that I am a socially and economically disadvantaged
individual who is an owner of the above-referenced firm seeking
certification as a Disadvantaged Business Enterprise or Airport
Concession Disadvantaged Business Enterprise. In support of my
application, I certify that I am a member of one or more of the
following groups, and that I have held myself out as a member of
the group(s): (Check all that apply):
Female Black American His
panic American
Native American Asian-Pacific American
Subcontinent Asian American Other (specify)
I certif
y that I am socially disadvantaged because I have been
subjected to racial or ethnic prejudice or cultural bias, or have
suffered the effects of discrimination, because of my identity
as a member of one or more of the groups identified above,
without regard to my individual qualities.
I further certify that my personal net worth does not exceed
$1.32 million, and that I am economically disadvantaged
because my ability to compete in the free enterprise system has
been impaired due to diminished capital and credit
opportunities as compared to others in the same or similar line
of business who are not socially and economically
disadvantaged.
I declare under penalty of perjury that the information
provide
d in this application and supporting documents is true
and correct.
Signature
(DBE/ACDBE Applicant) (Date)
NOTARY
CERTIFICATE
U.S. DOT Uni
form DBE / ACDBE Certification Application Page 14 of 15
UNIFORM CERTIFICATION APPLICATION
SUPPORTING DOCUMENTS CHECKLIST
In order to complete your application for DBE or ACDBE certification, you must attach copies of all of the following
REQUIRED documents. A failure to supply any information requested by the UCP may result in your firm denied
DBE/ACDBE certification.
Required Documents for All Applicants
Résumés (that include places of employme
nt with
corresponding dates), for all owners, officers, and key
personnel of the applicant firm
Personal Net Worth Statement for each socially a
nd
economically disadvantaged owners who the applicant firm
relies upon to satisfy the Regulation’s 51% ownership
requirement.
Personal Federal tax returns for the past 3 years, if
applicable,
for each disadvantaged owner
Federal tax returns (and reques
ts for extensions) filed by
the firm and its affiliates with related schedules, for the past 3
years.
Documented proof of contributions used to acquire
ownershi
p for each owner (e.g., both sides of cancelled
checks)
Signed loan and security agreemen
ts, and bonding forms
List of equipment and/or vehicles owned and leased
including VIN numbers, copy of titles, proof of ownership,
insurance cards for each vehicle.
Title(s), registration certificate(s), and U.S. DOT numbers
for each
truck owned or operated by your firm
Licenses, license renewal forms, permits, and haul
authority forms
Descriptions of all real estate (including office/storage
space, etc.)
owned/leased by your firm and documented proof
of ownership/signed leases
Documented proof of any transfers of assets to/from your
firm and/
or to/from any of its owners over the past 2 years
DBE/ACDBE and SBA 8(a), SDB, MBE/
WBE
certifications, denials, and/or decertification’s, if applicable;
and any U.S. DOT appeal decisions on these actions.
Bank authorization and signatory cards
Schedule
of salaries (or other remuneration) paid to all
o
fficers, managers, owners, and/or directors of the firm
List of all employees, job titles, and dates of employment.
Proof of warehouse/storage facility ownership or lease
arrangeme
nts
Partnership or Joint Venture
Original and any amended Partnership or Joint Venture
Agreement
s
Corporation or LLC
Official Articles of Incorporation (signed by the s
tate
official)
Both sides of all corporate stock certificates and your
firm’s sto
ck transfer ledger
ShareholdersAgreement(s
)
Minutes of all stockholders and board of director’s m
eetings
Corporate by-laws and a
ny amendments
Corporate bank resolution and bank signature cards
Official Certificate of Formation and Operating Agreement
with any am
endments (for LLCs)
Optional Documents to Be Provided on Request
The certifying agency to which you are applying may require
the submission of the following documents. If requested to
provide these document, you must supply them with your
application or at the on-site visit.
Proof of citizenship
Insurance agreements for each truck owned or operated by
your firm
Au
dited financial statements (if available)
Trust ag
reements held by any owner claiming
disadvant
aged status
Year-end balance sheets and income statements for the
past 3 years
(or life of firm, if less than three years)
Suppliers
List of product lines carried and list of distribution
equipment owned and/or leased
U.S. DOT Uniform DBE / ACDBE Certification Application Page 15 of 15
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