Fillable Unified Certification Application (City of Columbus)

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Unified Certification Application (City of Columbus)

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Unified Minority
& Women Business
Enterprise
Certication Alication
l
WBE
WOMEN
BUSINESS
ENTERPRISE
CITY OF COLUMBUS
OFFICE OF DIVERSITY
AND INCLUSION
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ODI shall make a prompt determination of the certification of all companies. Applicants
shall be notified within thirty (30) days after receipt of a complete application and all
required documentation.
An on-site visit is required to complete the certification process and shall be scheduled
during the thirty (30) day processing period. If the applicant is unavailable to participate
in an on-site review during this period, the processing period will be extended.
The applicant will be required to substantiate all information contained in this application
through submittal of supporting documentation as required by ODI. All information
divulged or submitted with this application shall be considered CONFIDENTIAL.
The City of Columbus’ Minority and Woman Business Certification is valid for up to
three (3) years. A random on site could occur during the certification period.
Please forward all requested information to:
Diversity and In
clusion Office
ATTN: Certification Program
1111 East Broad Street
2nd Floor, Suite 203
Columbus, Ohio 43205
Phone (614) 645-4764
Fax (614) 645-6669
facebook.com/odicolumbus twitter.com/odicolumbus
youtube.com/odicolumbus
D E F I N I T I O N S
A. “Minority Business Enterprise” (MBE) shall mean a business which is an
independent and continuing operation for profit, performing
a commercially
useful function, and is owned and controlled by one or more persons of African-
American, Asian-Indian, or Hispanic decent, and is a U.S. citizen, as defined by
C.C.C. 3901.01(k).
B. “Woman Business Enterprise” (WBE) shall mean a business which is an
independent and continuing operation for profit, performing a commercially
useful function, and is owned and controlled by one or more Women, and is a
U.S. citizens, as defined by C.C.C. 3901.01(p).
C. In order to be certified as a Minority Business Enterprise (MBE), or a
Woman Business Enterprise (WBE), a business must establish the following:
1. Business is at least 51% or more owned by one or more persons of
an eligible racial minority or woman gender.
2. Is managed and controlled by the minority or woman person seeking
to be certified.
3. It has been in business in the Columbus Metropolitan Service Area
(MSA) for at least six (6) months. These MSA counties include
Franklin, Delaware, Fairfield, Fayette, Licking, Madison, Pickaway
and Union.
4. Annual sales that do not exceed average industry sales for (3)
consecutive years, as determined by the federal tax returns for the firm
and by the 4-digit SIC code of the U.S. Economic Census data. If a
firm is engaged in more than one industry, the average annual sales
for its “industry” shall be determined by a weighted average of sales for
all industries it is engaged in.
5. Residency
(a) MBE or WBE has a place of business located within the corporation
limits of the City of Columbus as registered in official documents filed with
the Secretary of State, State of Ohio, or Franklin County Recorder’s
office.
(b) MBE or WBE holds a valid vendor’s license which indicates its place
of business is located within the corporation limits of the City of
Columbus.
C. “Minority group members” shall be those of African-American, Asian-
Indian, or Hispanic decent, and is a U.S. citizen, as defined by
C.C.C. 3901.01(k).
D. “Veteran” shall mean a person who served in the active military, naval, or air
service, and who was discharged or released therefrom
under conditions other than dishonorable, as defined by C.C.C. 3901.01(n).
E. “Days” shall mean generally accepted working days. Monday through Friday,
excluding national holidays.
F. “Certifying Agency”, for purposes of implementing MBE/WBE certification
policies and procedures, shall mean the City of Columbus Mayor’s Office of
Diversity and Inclusion is designated to manage certifications per the City’s
Equal Business Opportunity Code.
G. On-site visit – Owner interview at business location consisting or a review
of the worksite and verification of application information. There are
two types of on-site visits:
1. Scheduled – Prior notification shall be given.
2. Random – may occur anytime without notice, during and subsequent to
certification process.
H. Operating Radius
1. Local – City of Columbus
2. Regional – Columbus MSA
3. National – United States of America
CITY OF COLUMBUS CERTIFICATION APPLICATION
When answers require additional space, use plain white paper. Properly identify the item referred to by
the appropriate number. At the top of each additional answer and exhibit, state the
name of the
applicant, date
of
application and item number. Please answer all questions in English as completely as
possible. If a particular question does not apply to your business operation, write not applicable (NA) in
the space provided. You must include all attachments requested. The application must be notarized.
COMPANY IS APPLYING FOR CERTIFICATION AS A:
Minority Business Enterprise
Woman Business Enterprise
Veteran Registration
COMPANY NAME
CONTRACT COMPLIANCE VENDOR NUMBER
ADDRESS
(Number & Street)
STATE
ZIP
CITY
TELEPHONE
(Area Code)
FAX #
CONTACT PERSON
TITLE
LIST LOCATION OF ALL ADDITIONAL FACILITIES
EMAIL:
WEBSITE:
TYPE OF BUSINESS
(Check primary function)
Construction Contractor
Distribution
Transportation
Service
Broker
Professional Service
MAJOR PRODUCTS AND/OR SERVICES PROVIDED:
1
LEGAL STRUCTURE
Corporation
Partnership
Sole Proprietorship
Other
(Specify)
FEDERAL I.D. or SOCIAL SECURITY NUMBER
OPERATING RADIUS:
Local
Regional
National
ANNUAL SALES FOR LAST TWO YEARS
DATES OF FISCAL YEAR
Year 20 ____ $ __________
Year 20 ____ $ __________
HAS COMPANY DONE OR IS IT CURRENTLY DOING BUSINESS UNDER ANOTHER NAME?
Yes
No If yes, give former name:
Date Business Was Established: __________ / __________ / __________ (Month, Day, Year)
Type of Acquisition (Check One)
Bought existing business
Started business
Secured a franchise
Merger or consolidation
Other (please specify) ___________________________
IDENTIFY ALL OWNERS OF BUSINESS BY NAME, GENDER, RACE AND PERCENTAGE OF
OWNERSHIP AND CONTROL:
NAME
GENDER
MINORITY
U.S. CITIZEN
YEARS
% OWNED
VOTING %
2
NAME
OFFICE
RACE
GENDER
SALARY
IF COMPANY IS LESS THAN 100% MINORITY/FEMALE OWNERSHIP LIST:
A. Capital contributions by minority/female owner(s)
$ ________Cash
$ ________Loan
B. Capital contributions by non-minority/female owner(s)
$ ________Cash
$ ________Loan
C. Equipment supplied by minority/female owner(s) _______________________________________________
D. Equipment supplied by non-minority/female owner(s) ___________________________________________
E. Real estate supplied by non-minority/female owner(s) ___________________________________________
F. Real estate supplied by non-minority/female owner(s) ___________________________________________
G. Area(s) of expertise of non-minority/female owner(s) ____________________________________________
H. Area(s) of expertise of non-minority/female owner(s) ____________________________________________
HOW WAS COMPANY STARTED OR ACQUIRED?
Cash/Capital $ __________ (submit canceled check(s)/other documents) __________________________
Loan $ __________ (submit loan documentation) ______________________________________________
Gift (explain/submit documentation) _________________________________________________________
Payment of Services (explain/submit documentation) ___________________________________________
Inherited (explain/submit documentation) _____________________________________________________
Other _________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3
IDENTIFY BY NAME, RACE, GENDER, TITLE, AND JOB CLASSIFICATION, THOSE INDIVIDUALS IN THE COMPANY
WHO ARE RESPONSIBLE FOR DAY-TO-DAY MANAGEMENT AND POLICY DECISION MAKING, INCLUDING, BUT
NOT LIMITED TO, THOSE WITH PRIME RESPONSIBILITY FOR: (INCLUDE OWNERS AND NON-OWNERS)
NAME
RACE
GENDER
TITLE
FINANCIAL DECISIONS
SIGNING OF CHECKS
PAYROLL
PURCHASING
OTHER
ESTIMATING
SALES/MARKETING
HIRING/FIRING OF
MANAGEMENT PERSONNEL
PURCHASES OF MAJOR ITEMS/SUPPLIES
SUPERVISION FIELD OPERATIONS
NEGOTIATING/SIGNING CONTRACTS
CREDIT ACQUISITION
MANAGEMENT DECISIONS
BID NEGOTIATIONS/SCHEDULING
OFFICE MANAGEMENT
BONDING/INSURANCE
OPERATING MANAGEMENT
IS ANY PERSON LISTED IN ITEMS ABOVE, INCLUDING SPOUSE AND IMMEDIATE FAMILY MEMBERS, CURRENTLY OR
HAS BEEN PREVIOUSLY AFFILIATED OR ASSOCIATED IN ANY CAPACITY WITH ANY OTHER CONCERN(S)
OPERATING IN THE SAME OR SIMILAR TYPE OF BUSINESS AS APPLICANT’S CONCERN?
YES
NO
(IF YES, COMPLETE THE FOLLOWING)
NAME
BUSINESS NAME
AFFILIATION
IF THERE IS A BUSINESS RELATIONSHIP EXISTING BETWEEN THE APPLICANT AND A MAJORITY BUSINESS,
DOES THE RELATIONSHIP INCLUDE SHARED: (CHECK THE ITEMS THAT APPLY)
Owners
Space
Financing
Employees (if checked see below)
4
NAME
RACE
GENDER
TITLE/JOB
DESCRIPTION
HAS COMPANY RECEIVED CERTIFICATION AS A MINORITY BUSINESS ENTERPRISE OR WOMAN BUSINESS
ENTERPRISE FROM ANY OTHER AGENCY?
YES
NO
If yes, provide:
NAME OF CERTIFYING AGENCY_______________________________________________________
DATE RECEIVED ____________________________________________________________________
(Provide additional agencies on an attached sheet)
HAS THE COMPANY OR ANY OTHER COMPANY WITH ANY OF THE SAME OFFICERS BEEN DENIED CERTIFICATION?
YES
NO
If yes, provide:
NAME OF CERTIFYING AGENCY_______________________________________________________
DATE RECEIVED ____________________________________________________________________
(Provide additional agencies on an attached sheet)
CURRENT EMPLOYMENT DATA
Number of actual employees:
Female
Male
_____ African American
_____ African American
_____ Hispanic
_____ Hispanic
_____ Asian Pacific
_____ Asian Pacific
_____ Native American
_____ Native American
_____ Asian Indian
_____ Asian Indian
_____ Caucasian
_____ Caucasian
5
THE FOLLOWING ATTACHMENTS ARE REQUIRED FOR CERTIFICATION:
1. Two business credit references, include names of companies, contact person
and title, address, and telephone number.
2. Copy of licenses required by city or state.
3. Submit evidence of all outstanding loans.
4. Resume of principals (s).
5. Office rental or lease agreements.
6. Bank resolution/signature card.
7. Birth Certificates of minority principals (s).
8. Submit business capability statement.
9. If you are a Veteran, please include DD214
SOLE PROPRIETORSHIP
Individual Federal Income taxes for the past three (3) years
Company’s Federal taxes for the past three (3) years (all available if less than 3 years)
Company’s last financial statement
PARTNERSHIP
Individual Federal Taxes of partners for the past three (3) years (all available if
less than 3 years)
6
o Company’s Federal taxes for the past three (3) years (all available if less than 3 years)
o Company’s last financial statement
o Partnership Agreement
CORPORATION
o Individual Federal Income taxes for the past three (3) years (all available if less
than 3 years)
o Company’s Federal taxes for the past three (3) years (all available if less than
3 years)
o Company’s last financial statement
o Articles of Incorporation (attach copy of certificate from Secretary of State) and
Bylaws
o Copy of Stock Certificate (s) issued
o Agreements containing options to purchase or otherwise acquire stock
o Shareholder guarantees for any debt
o Schedule of advances made to corporations by shareholders for the
proceeding three (3) years
o Minutes of first board or shareholders meeting
ADDITIONALLY, YOU MAY BE REQUIRED TO SUBMIT THE FOLLOWING:
1. Equipment rental or lease agreements.
2. Listing of all equipment owned or leased.
3. Vehicles owned and copies of memorandum of title.
4. Dun & Bradstreet number, if any.
5. Proof of capital invested.
6. W2’s of principals.
7
Read the following paragraphs carefully! Your signature on this application
indicates acceptance and understanding of the conditions.
o OMISSION of information may be cause for this application not
receiving timely and complete consideration.
o THE CERTIFYING AGENCY RESERVES THE RIGHT to request
further information from the applicant prior to certification.
o APPLICANT AGREES to immediately notify the certifying agency if there
is any significant change in the information submitted, including, but not
limited
to an impact on ownership and/or control.
o ALL INFORMATION in this application is true and accurate and
is submitted for consideration of certification.
o IF the certifying agency determines that substantial evidence is available
which indicates the applicant has committed fraud, the matter shall be
referred to the City Attorney for criminal prosecution per Section 3938.02
of the Columbus City Code.
o IF THE APPLICANT is awarded certification, the applicant agrees to abide
by all rules governing their status as may be determined by the certifying
agency from time to time.
The undersigned hereby swears, under penalty of law, that all
statements made in this application are true.
The undersigned agrees to hold the certifying agency harmless from
any claim arising out of this application and agrees to indemnify said
agency from any liability in connection with the certification of the
applicant.
8
AFFIDAVIT OF APPLICATION
The undersigned swears or affirms that the information submitted in this Certification Application
relative to _____________________________________ (Company Name) is true and further swears
or affirms that there has been no substantive change in ownership and control of this company.
The undersigned further agrees to provide written information relative to any future changes in
ownership and/or management of the company to the City of Columbus Mayor’s Office of Diversity and
Inclusion immediately following the change. The undersigned understands that if the change in
information is not submitted, decertification may occur. Any material misrepresentation of information
contained herein will be grounds for decertification.
If the certifying agency determines that substantial evidence is available which indicates the applicant
has committed fraud, appropriate action shall be taken.
_________________________________________
(Name, Print)
__________________________________
(Title)
_________________________________________
(Signature)
__________________________________
(Date)
State of ________________________ County of __________________________________
On this the _______________day of ______________________, 20 _____, before me appeared
(Name) ___________________________________, who affirmed that he or she was properly
authorized by
(Name of Company) __________________________to execute the Affidavit and did so as his or her free
act and deed.
(Seal) Notary Public _______________________________ My Commission Expires _______________
Rev. 2019
9
AFFIDAVIT
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Unified Certification Application (City of Columbus)

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