6100-1e EPA DBE Certification Application (Alaska Native Corpora

Environmental Protection Agency

OMB Control No: ______
Approved:
______
Approval Expires: ______

EPA DBE Certification Application
For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE)
Under EPA’s Disadvantaged Business Enterprise (DBE) Program
Alaska Native Corporation (ANC) Owned Concern
Name of Alaska Native Corporation (ANC): _______________________________________________
Address of ANC: ______________________________________________________________________
Name of President/CEO: __________________________________
EIN: _________________________ E-mail Address:_________________________________________
Business Address:______________________________________________ County:_______________
City:_________________________________ State:_______________ Zip Code:__________________
Phone Number:___________________________ Fax Number:________________________________
Mailing Address (if different than above):________________________ County:_________________
City:_________________________________ State:_______________ Zip Code:__________________
What is the firm’s 4-digit primary North American Industrial Classification (NAIC) code?
_____________________________________________________________________________________
Is your firm certified by the Small Business Administration under its 8(a) Business Development
Program?___ Yes ___ No. If yes, provide Pro-Net number: _________________________________
Is your firm certified by the Small Business Administration under its Small Disadvantaged
Business (SDB) Program? ___ Yes ___ No. If yes, provide Pro-Net number: ____________________
Is your firm certified as a DBE by a U.S. Department of Transportation recipient? ___ Yes ___ No.
If yes, provide State(s) and ID number(s): ________________________________________________
Is your firm certified by a State government, local government, Indian tribal government, or
independent private organization? ___ Yes ___ No. If yes, provide ID number and the certifying
entity: ________________________________________________________________________________
Has your firm ever been denied certification by a Federal agency, State government, local
government, Indian tribal government, or independent private organization? ___ Yes ___ No. If
yes, provide explanation/documentation:__________________________________________________
_____________________________________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1e)
(Alaska Native Corporations)

Do you have any other certification as a disadvantaged business entity, i.e., MBE, DBE, WBE, etc?
___Yes ___ No. If yes, provide State(s) and ID number(s): ________________________________
Is the applicant ANC business corporation a for profit corporation? ___ Yes ___ No.

EPA DBE Certification Application (EPA Form 6100-1e)
(Alaska Native Corporations)

2

Business Eligibility
SECTION A
Social Disadvantage
1.

An Alaska Native Corporation that that meets the following criteria is considered socially
disadvantaged:
Alaska Native Corporation or ANC means any Regional Corporation, Village Corporation,
Urban Corporation, or Group Corporation organized under the laws of the State of Alaska in
accordance with the Alaska Native Claims Settlement Act, as amended (43 U.S.C. 1601, et seq.).
Provide documentation that the applicant entity meets these criteria as Attachment A-1.

SECTION B
Economic Disadvantage
1.

Do Alaska Natives and descendants of Natives own a majority of both the total equity of the
ANC and the total voting powers to elect directors of the ANC through their holdings of
settlement common stock? ___ Yes ___ No. If yes, provide verification of the percentage of
Alaska Native ownership as attachment B-1.

SECTION C
Ownership
1. Does the ANC and holders of its settlement common stock own at least 51% interest in the
ANC? Please provide documentation as attachment C-1.
2.

If more than one class of stock, provide information for each class:
Voting
a) Total number of shares authorized:
b) Total number of shares currently outstanding:

3.

_____
_____

Non- Total
Voting
______ _____
______ _____

List all entities, individuals, and/or trusts that have an ownership interest in the applicant
firm.
Name
Title
Ownership
Percent
Voting Non-voting
Total
___________________________
____________________ ______ _________
______
___________________________

____________________ ______ __________

______

___________________________

____________________ ______ __________

______

___________________________

____________________ ______ __________

______

EPA DBE Certification Application (EPA Form 6100-1e)
(Alaska Native Corporations)

3

4.

Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did
ownership affect the disadvantaged status of your firm? Please explain as Attachment C-2.

SECTION D
Control and Management
1.

Are the management and daily business operations of the applicant firm controlled by the
ANC through one or more disadvantaged individual members who possess sufficient
management experience of an extent and complexity to run the concern? ___Yes ___No. If
yes, provide documentation to verify tribal membership and management competency as
Attachment D-1.

2.

Are members of the management team, business committee members, officers, and directors
engaged in any outside employment or other business interests which conflict with the
management of the applicant firm? ___ Yes ___ No.

3.

List the titles of all officers, directors, management members, partners and key managers and
the hours devoted, by such individual(s) to the management of the applicant firm.

4.

Name

Title

Hours

____________________________

_______________________________

__________

____________________________

_______________________________

__________

____________________________

_______________________________

__________

____________________________

_______________________________

__________

List the names of all individuals who have access to the firm’s bank account.
Name
___________________________

Title
__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

EPA DBE Certification Application (EPA Form 6100-1e)
(Alaska Native Corporations)

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Each person signing below:
1.

Certifies that the applicant firm is at least 51% owned and controlled by an Alaska Native
Corporation (ANC).

2.

Certifies that the information provided with regard to the applicant firm’s economic
disadvantaged status is true, accurate, and complete to the best of his/her knowledge and
belief.

3.

Certifies that the information provided with regard to the applicant firm’s ownership and
control status is true, accurate, and complete to the best of his/her knowledge and belief.

4.

Certifies that the information provided, including that shown on documents accompanying
this application, is true, accurate, and complete to the best of his/her knowledge and belief.

5.

Acknowledges that EPA, at its discretion, may give the information submitted to Federal,
state and local agencies to determine violations of law.

6.

Acknowledges that EPA’s approval of an application does not affect the Government’s
right to pursue criminal prosecution for incorrect or incomplete information given on the
application form, even if correct information has been included in other materials
submitted to EPA.

Name

SSN

Date

________________________

_______________________

______________________

________________________

_______________________

______________________

________________________

_______________________

______________________

________________________

_______________________

______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average
three (3) hours. Burden means the total time, effort, or financial resources expended by persons to
generate, maintain, retain, or disclose or provide information to or for a Federal agency. This includes
the time needed to review instructions; develop, acquire, install, and utilize technology and systems for
the purposes of collecting, validating, and verifying information, processing and maintaining
information, and disclosing and providing information; adjust the existing ways to comply with any
previously applicable instructions and requirements; train personnel to be able to respond to a collection
of information; search data sources; complete and review the collection of information; and transmit or
otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments on the Agency’s need for this information, the accuracy of the provided burden
estimates, and any suggested methods for minimizing respondent burden, including the use of
automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental
Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed EPA DBE Certification Form to this
address.

EPA DBE Certification Application (EPA Form 6100-1e)
(Alaska Native Corporations)

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