Appendix F UNIFORM CERTIFICATION APPLICATION

Uniform Report of DBE Awards/Commitments and other DBE Program Collections

Appendix F

Report of DBE Awards and Commitments

OMB: 2105-0510

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Appendix F

U.S. DEPARTMENT OF
TRANSPORTATION
UNIFORM CERTIFICATION APPLICATION
DISADVANTAGED BUSINESS ENTERPRISE /
AIRPORT CONCESSION DISADVANTAGED
BUSINESS ENTERPRISE

49 C.F.R. PARTS 23 and 26
Send Application To:
[UCP PARTICIPATING MEMBER]
[Address]
[Phone:] [Fax]
A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS
SUFFICIENT 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.

____________________________________________________________________________________________________
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 CFR section 26.5 and the Airport Concession Disadvantaged Business Enterprise Program as defined in 49 CFR
section 23.3. You may review DOT’s complete Privacy Act Statement in the Federal Register published on April 11, 2000 (65 FR 19477).

Roadmap for Applicants
1. Should I apply?
You may be eligible to participate in the DBE/ACDBE program if you answer "Yes" to the following:
 Is your firm organized as a for-profit business that performs or seeks to perform transportation related
work for a recipient of Federal Transit Administration, Federal Highway Administration, or Federal
Aviation Administration funds?
 Is your firm at least 51% owned by a socially and economically disadvantaged individual(s) who also
controls the firm?
 Is the disadvantaged owner a U.S. citizen or lawfully admitted permanent resident of the U.S.?
 Is your firm a small business that meets the Small Business Administration's (SBA's) size standard and
does not exceed $22.41 million in gross annual receipts for DBE ($52.47 million for ACDBEs)? (Note,
other size standards apply ACDBE applications from banks/financial institutions, car rental companies,
pay telephone firms, and automobile dealers.)
2. How do I apply?
You must complete and submit this certification application and related material to an agency in your
home state; and second 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.
3. Who will contact me about my application and what are the eligibility standards?
The DBE and ACDBE Programs require that all U.S. DOT recipients of federal assistance must
participate in a statewide Unified Certification Program (UCP). The UCP is a one-stop certification
procedure that eliminates the need for your firm to obtain certification from multiple agencies within the
state. The UCP is responsible for certifying firms and maintaining a database of certified DBEs and
ACDBEs for DOT grantees, pursuant to the eligibility standards found in 49 CFR Parts 23 and 26.
4. Where can I find more information?
U.S. DOT—http://www.osdbu.dot.gov/DBEProgram/index.cfm (This site provides useful links to the
rules and regulations governing the DBE/ACDBE programs, questions and answers, and other pertinent
information)
http://www.census.gov/eos/www/naics/ (provides a listing of NAICS codes) and
http://www.sba.gov/content/table-small-business-size-standards (SBA has established a Table of Small
Business Size Standards that is matched to the North American Industry Classification System (NAICS)
for industriesprovides a listing of NAICS codes and size standards)
Under 49 CFR §26.107, dated February 2, 1999, if at any time, the 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 49 CFR Part 29, Governmentwide Debarment
and Suspension (nonprocurement) and Governmentwide Requirements for Drug-free Workplace (grants), take enforcement
action under 49 CFR 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.

INSTRUCTIONS FOR COMPLETING THE
DISADVANTAGED BUSINESS ENTERPRISE
AIRPORT CONCESSIONS DISADVANTAGED BUSINESS ENTERPRISE
UNIFORM CERTIFICATION APPLICATION
NOTE: 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

Section 2: GENERAL INFORMATION

A. Business profile:

Basic Contact Information
(1) State the contact person and title of the person
completing this application and the person who will
serve as your firm's primary contact for this
application.
(2) State the legal name of your firm, as indicated in
your firm's Articles of Incorporation or charter.
(3) State the primary phone number of your firm.
(4) State a secondary phone number, if any.
(5) State your firm's fax number, if any.
(6) State the contact person's email address.
(7) State your firm's website address, if any.
(8) State the street address of your firm (i.e. the
physical location of its offices—not a post office box
address).
(9) State the mailing address of your firm, if it is
different from your firm’s street address. Check the
box if this is homes based business and identify who
holds title to the property.

Prior/Other Certifications and Applications
(10) Check the appropriate box indicating for which
program your firm is currently certified. If you are
already certified as a DBE/ACDBE, indicate in the
appropriate box the name of the certifying agency that
certified your firm, and also indicate whether your
firm has undergone an onsite visit. If your firm has
already undergone an onsite visit/review, indicate the
dates of the review(s) and the state UCP(s) that
conducted the review.
(11) Indicate whether your firm or any of the persons
listed has ever been denied certification as a DBE,
8(a), or 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).

(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. 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.
(2) Identify the appropriate NAICS Code for the
line(s) of work you identified in your business profile.
(3) State the date on which your firm was officially
established as stated in your firm’s Articles of
Incorporation or charter.
(4) State the date on which you and/or each other
owner took ownership of the firm.
(5) Check the appropriate box that describes 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.” NOTE: If you checked “No,”
then you do NOT qualify for the DBE/ACDBE
program and should not complete the rest of this
application. All participating firms must be for-profit
enterprises. If the firm is a for profit enterprise,
provide the Federal Tax ID number as stated on your
firm’s filed tax returns, if you have one. This could
also be the Social Security number of the owner of
your firm.
(7) Check the appropriate box that describes the legal
form of ownership 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) Check the appropriate box that indicates whether
your firm has ever existed under different ownership,
a different type of ownership, or a different name. If
you checked “Yes,” explain the circumstances in the
space provided.
(9) 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.
(10) Specify the total gross receipts of your firm for
each of the past three years, as declared in your firm’s
filed tax returns. You must submit complete copies of
the firm’s State and Federal tax returns for each year

and audited financial statements (if available). If there
are any affiliates or subsidiaries of the applicant firm
or owners, you must submit complete copies of these
firm(s) state and federal tax returns. Affiliation is
defined in 49 CFR §26.5 and 13 CFR part 121.
B.

provide completed copies of this section for each additional
owner):
A.

(1) Give the name of the owner.
(2) State his/her title or position within your firm.
(3) Give his/her home phone number.
(4) State 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. If this owner is not a U.S.
citizen, check the appropriate box that indicates
whether this owner is 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. This, however, does not necessarily disqualify
your firm altogether from the DBE program if another
owner is a U.S. citizen or lawfully admitted permanent
resident and meets the program’s other qualifying
requirements.
(8) (a)(i) State the personal net worth of each owner
claiming to be socially and economically
disadvantaged applying for DBE qualification. (Each
owner claiming disadvantaged status must submit a
separate statement. (ii) State whether a trust has been
created for the benefit of this owner. If you answered
“Yes,” briefly explain the nature, history, purpose, and
current value of the trust(s). NOTE: You only need to
complete this section for each owner that is
applying for DBE qualification (i.e., for each owner
who is claiming to be “socially and economically
disadvantaged” and whose ownership interest is to
be counted toward the control and 51% ownership
requirements of the DBE program) Use the PNW
form at the end of this application to compute each
disadvantaged owner’s PNW.

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.
(3) Check the appropriate box that indicates whether
at present or at any time in the past your firm:
(a) has been a subsidiary of any other firm;
(b) existed as a partnership in which one or more of
the partners are/were other firms;
(c) has owned any percentage of any other firm; and
(d) has had any subsidiaries of its own.
(e) has 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)(ae), describe the subsidiaries, partnership interests or
other arrangements. In addition, explain whether these
relationships are continuing today, or if not, when they
ended.
C.

Immediate Family Member, Manager, or
Employee Businesses
Check the appropriate to indicate whether any of your
immediate family members, managers, or employees,
own, manage, or are associated with another company.
An “immediate family member” is any person who is
your father, mother, husband, wife, son, daughter,
brother, sister, grandmother, grandfather, grandson,
granddaughter, mother-in-law, or father-in-law. If you
answered “Yes,” provide the name of each person,
your relationship to them, the name of the company
they own or manage the type of business, and whether
they own or manage the company.

Section 3: 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,

Background Information

Ownership Interest
(1) State the number of years during which this
owner has been an owner of your firm.
(2) 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
the shares. Attach documentation substantiating this
investment.
(3) Indicate the number, percentage of the total,
class, date acquired, of stock acquired by the owner.
(4) Describe the familial relationship of this owner to
each other owner of your firm and employees.
(5) Check the appropriate box that indicates 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
title or function held in that business.

(4) Marketing and sales
(5) Supervising field operations
(6) Attending bid openings and lettings
(7) Perform office management, such as billing,
accounts receivable, and accounts payable
(8) Hires and fires management staff
(9) Hire and fire field staff or crew
(10) Designates profit spending or investment
(11) Obligates the business by
contract/credit/bond/insurance
(12) Purchase equipment
(13) Signs business checks

(6) (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 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.
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
of your firm.
(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. 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.
(5) Check the appropriate box to that indicates
whether the applicant business and/or owner is
involved in any present or pending litigation or
administrative proceedings. If you answered “Yes,”
provide details of the litigation or administrative
proceedings.

Check the appropriate box that indicates whether any
of the persons listed in (1) through (13) above perform
a management or supervisory function for any other
business. If yes 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.

(1) Equipment and Vehicles
State the type, 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 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.

Duties of Owners, Officers, Directors, Managers,
and Key Personnel
In the chart provided, specify the roles of the majority
and minority owners, directors, officers, and
managers, and key personnel who perform significant
functions for the business. Make enough copies of this
form to provide information on each and every person.
Submit résumés for each owner and non-owner
identified below. State the name of the individual,
title, race, percentage of the firm that they own,
gender, salary and benefits.

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,” briefly explain the nature of that reliance and
the extent to which the other firm carries out such
functions.

Circle the frequency of each person’s involvement as
follows: “always, frequently, seldom, or never”
E.
(1) Setting policy for company direction/scope, or
financial decisions.
(2) Bidding and estimating including calculation of
cost estimates, bid preparation and submission;
(3) Making purchasing decisions

Indicate firm inventory in the following categories:

Financial / Banking Information
Banking Information. State the name and address of
your firm’s bank. In the space provided, identify the
individuals able to sign checks on this account.

Bonding Information. State your firm’s Binder
Number. State the name of your firm’s bond agent
and/or broker. Give your agent’s/broker’s phone
number. Give your agent’s/broker’s address. State
your firm’s bonding limits (in dollars), specifying both
the aggregate and project limits.
F.

Identify all sources, amounts, and purposes of
money loaned to your firm, including the names of
persons or firms securing 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.

G. List all 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. List 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 the license/permit number and issuing State of the
license or permit.
I.

List the three 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.

List the three 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.

AIRPORT CONCESSION (ACDBE) APPLICANTS
Identify the concession space, address and location at the
airport, the value of the property or lease, and fees/lease
payments paid to the airport. Provide information
concerning any other airport concession businesses the
applicant firm or any affiliate owns and/or operates,
including name, location, type of concession, and start date
of the concession enterprise.

AFFIDAVIT & SIGNATURE
The Affidavit of Certification must accompany your
application for DBE/ACDBE certification. 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.

UNIFORM DBE/ACDBE CERTIFICATION APPLICATION

Date________

Section 1: CERTIFICATION INFORMATION

A. Basic Contact Information
(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:
________ - ____

Home Based Business?  Yes No

If Yes, who holds the title to the property? ______________________

B. Prior/Other Certifications and Applications
(10) Is your firm currently certified for any of the following programs? (If Yes, check appropriate box(es))

 DBE  ACDBE Names of certifying agencies: ______________________________________________
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: ___________________________
Date ____/ ____/____ State/UCP Member: ___________________________
You will be required to provide a copy of the above on-site reports as part of this application process.

Already certified in your home state?  STOP! You may not have to complete this application. Ask your
state UCP about the streamlined application process.
(11) Has your firm (under any name) or any firm owned or controlled by your firm’s owners, Board of
Directors, officers or management personnel, ever been:
(a) Denied certification as a DBE, ACDBE, 8(a), SDB, MBE/WBE firm?  Yes No
(b) Decertified from these programs?
 Yes No
(c) 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 to any of the above, identify all state, local, or Federal agencies and explain the nature of the action(s):
___________________________________________________________________________________________
If you appealed this decision to USDOT, what was the result? Please attach a copy of USDOT’s decision(s).
___________________________________________________________________________________________

_____________________________________________________________________________________
U.S. DOT Uniform DBE / ACDBE Certification Application  Page 1 of 14

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 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: ____/____/____

(5) Method of acquisition (Check all that apply):

 Started new business
 Bought existing business
 Inherited business
 Merger or consolidation  Other (explain) _____________________________
(6) Is your firm “for profit”?  Yes No→

 Secured concession

 STOP! If your firm is NOT for-profit, then you do NOT
qualify for this program and should not fill out this application.

Employer’s ID # ________________________
Federal Tax ID# ________________________
(7) Type of Legal Business Structure: (check all that apply):







Sole Proprietorship
 Limited Liability Partnership
Partnership
Corporation
Limited Liability Corporation  Joint Venture (Identify all JV partners __________________________)
Applying as an ACDBE
Other, Describe: _______________________________________________

(8) Has your firm ever existed under different ownership, a different type of ownership, or a different name?

 Yes  No If Yes, explain: _______________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
(9) Number of employees: Full-time ________

Part-time ________

Seasonal ________Total _________

(Please attach a list of employees, their job titles, and dates of employment, to your application).
Year _______ Total receipts $ _________________
(10) Specify the firm’s gross receipts for the last 3 years.
You must submit complete copies of the firm’s State and
Year _______ Total receipts $ _________________
Federal tax returns for each year, and audited financial
statements (if available). If there are any affiliates or
subsidiaries of the applicant firm or owners, you must submit Year _______ Total receipts $ _________________
complete copies of these firms’ State and Federal tax returns.
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 2 of 15

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 fully 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.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

(2) Has any other firm had an ownership interest in your firm at present or at any time in the past?

 Yes  No If Yes, explain____________________________________________________________________
(3) At present, or at any time in the past, has your firm:
(a) been a subsidiary of any other firm?  Yes  No
(b) existed as a partnership in which one or more of the partners are/were other firms?  Yes  No
(c) owned any percentage of any other firm?  Yes  No
(d) had any subsidiaries?  Yes  No
(e) been a subcontractor with another firm 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)-(e), describe the subsidiaries, partnership interests,
or other arrangements and whether this continues. Please attach a separate sheet if necessary.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
C. Immediate Family Member, Manager, or Employee Businesses
Do any of your immediate family members, managers, or employees own, manage, or are associated with another
company?  Yes  No If Yes, then list: (Please attach extra sheets, if needed):
Name

Relationship

Company

Type of Business

Own/Manage/Associated with

1. __________________________________________________________________________________________
2. _________________________________________________________________________________________
3. _________________________________________________________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 3 of 15

Section 3: MAJORIY OWNER INFORMATION
A. In this section, specify the majority owner of the firm holding 51% or more ownership interest.
(1) Full Name:
____________________________

(2) Title:
_________________________

(4) Home Address (Street and Number):

City:
____________________

____________________________________________________

(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:


Birth Naturalized
Lawfully Admitted Permanent Resident

(3) Home Phone #:
(
) _____ - _______
State:
________

Zip:
_________ - ______

(8)(a) Economic Disadvantaged Status: Complete this
section only for each owner claiming to be socially and
economically disadvantaged applying for DBE qualification.

(i) What is the Personal Net Worth of the owner applying for
DBE/ACDBE qualification? $______________
(Use and attach the Personal Financial Statement form attached to
this application. Each owner must submit a separate statement).

(ii) Has any trust been created for the benefit of this
disadvantaged owner(s)?  Yes  No
If Yes, provide a copy (Attach additional sheets if needed):

B. Ownership Interest
(1) Number of years as owner: _______
(3) Percentage owned: ________ %
Class of stock owned: ______
Date acquired ______
(4) Describe familial relationship to other owners and
employees:_____________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

(2) Initial investment to
acquire ownership
interest in firm:

Type
Cash
Real Estate
Equipment
Other

Dollar Value
$
$
$
$

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)

(5) Does this owner perform a management or supervisory function for any other business?  Yes  No
If Yes, identify: Name of Business: __________________________________ Function/Title: _______________________________
(6)(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 than name of the business, and the nature of the relationship, and the owner’s function at the firm:
___________________________________________________________________________________________
(b) Does this owner work for any other firm, non-profit organization, or is engaged in any other activity
more than 10 hours per week? If yes, identify this activity: __________________________________________

U.S. DOT Uniform DBE/ACDBE Certification Application  Page 4 of 15

Section 3: OWNER INFORMATION, Cont’d.
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in
your firm (If more than one owner holding less than 51%, attach separate sheets for each additional owner)
(1) Full Name:
____________________________

(2) Title:
_________________________

(4) Home Address (street and number):

City:
____________________

____________________________________________________

(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:


Birth Naturalized
Lawfully Admitted Permanent Resident:

(3) Home Phone #:
(
) _____ - _______
State:
________

Zip:
_________ - ______

(8)(a) Economic Disadvantaged Status: Complete this
section only for each owner claiming to be socially and
economically disadvantaged applying for DBE qualification

(i) What is the Personal Net Worth of the owner applying for
DBE/ACDBE qualification? $_______________
(Use and attach the Personal Financial Statement form attached to
this application. Each owner must submit a separate statement).

(ii) Has any trust been created for the benefit of this
disadvantaged owner(s)?  Yes  No
If Yes, please explain (attach additional sheets if needed):

B. Ownership Interest
(1) Number of years as owner: _______
(3) Percentage owned: ________ %
Class of stock owned: ______
Date acquired ______
(4) Describe familial relationship to other owners and
employees:_____________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

(2) Initial investment to
acquire ownership
interest in firm:

Type
Cash
Real Estate
Equipment
Other

Dollar Value
$
$
$
$

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

Section 4: CONTROL
A. Identify your firm’s Officers and Board of Directors
(If additional space is required, attach a separate sheet):

Name
(1) Officers
of the
Company
(2) Board of
Directors

Title

Date
Appointed

Ethnicity

Gender

(a)
(b)
(c)
(d)
(e)
(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: ______________________________________________
Person: __________________________________ Title: _________________________________________________
Business: ________________________________ Function: ______________________________________________

(4) Do any of the persons listed (1) and/or (2) 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: __________________________________________________________________________

(5) Is the applicant business and/or owner involved in any present or pending lawsuits?


 Yes  No If Yes, provide details:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

U.S. DOT Uniform DBE/ACDBE Certification Application  Page 6 of 15

B. Duties of Owners, Officers, Directors, Managers, and Key Personnel
Complete for all owners and non-owners who perform significant functions for the business. Make enough copies
of this form to provide information on each and every person. Submit résumés for each person identified below.
Circle the frequency of each person’s involvement as follows:
Majority Owner (51% or more)
Name: _______________________
Title: ________________________
Race:________________________
Percent Owned:________________
Gender: _____Male _____Female
Salary: $______________________
Other Benefits $________________

Minority Owner (49% or less)
Name: _______________________
Title: ________________________
Race:________________________
Percent Owned:________________
Gender: _____Male _____Female
Salary: $______________________
Other Benefits $______________

Sets policy for company
direction/scope/ of operations

Bidding and estimating

Major purchasing decisions

Marketing and sales

Supervises field operations

Attend bid opening and lettings

Perform office management, such as
billing, accounts receivable and
accounts payable, etc.
Hires and fires management staff

Hire and fire field staff or crew
Designates profits spending or
investment

A
A

F
F

S
S

N
N

A
A

F
F

S
S

N
N

Obligates business by
contract/credit/bond/insurance

Purchase equipment

Signs business checks

A= Always
F = Frequently
S = Seldom
N = Never

Do any of the persons listed above 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.)  Yes  No
If Yes, describe the nature of the business relationship: ______________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 7 of 15

B. Duties of Owners, Officers, Directors, Managers, and Key Personnel, continued.
Complete for all owners and non-owners who do anything listed below for the business. Make enough copies of
this form to provide information on each and every person. Submit résumés for each person identified below.
Circle the frequency of each person’s involvement as follows:
Person 3
Name: _______________________
Title: ________________________
Race:________________________
Percent Owned:________________
Gender: _____Male ____Female
Salary: $______________________
Other Benefits $________________

Person 4
Name: _______________________
Title: ________________________
Race:________________________
Percent Owned:________________
Gender: _____Male ____Female
Salary: $______________________
Other Benefits $______________

Sets policy for company
direction/scope/ of operations

Bidding and estimating

Major purchasing decisions

Marketing and sales

Supervises field operations

Attend bid opening and lettings

Perform office management, such
as billing, accounts receivable and
accounts payable, etc.

Hires and fires management staff

Hire and fire field staff or crew
Designates profits spending or
investment

A
A

F
F

S
S

N
N

A
A

F
F

S
S

N
N

Obligates business by
contract/credit/bond/insurance

Purchase equipment

Signs business checks

A= Always
F = Frequently
S = Seldom
N = Never

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, describe the nature of the business relationship: _______________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 8 of 15

C. Inventory:
Indicate your firm’s inventory in the following categories (Please attach additional sheets if needed):
Equipment and Vehicles (Provide titles, proof of ownership, or signed lease agreements for the items listed)
Type of Equipment or Vehicle
Owned or Leased by
(Make and Model)
Current Value
Firm or Owner?
Where is this item stored?
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
5. __________________________________________________________________________________________
6. __________________________________________________________________________________________
7. __________________________________________________________________________________________
8. __________________________________________________________________________________________
9. __________________________________________________________________________________________
10. _________________________________________________________________________________________
11. _________________________________________________________________________________________
12. _________________________________________________________________________________________
13. _________________________________________________________________________________________
14. _________________________________________________________________________________________
15. _________________________________________________________________________________________
16. _________________________________________________________________________________________
Office Space (Provide signed lease agreements for the properties listed)
Street Address
Owned or Leased Current Value of Property or Lease
by Firm or
Owner?
1.__________________________________________________________________________________________
2. _________________________________________________________________________________________
Storage Space (Provide signed lease agreements for the properties listed)
Street Address
Owned or Leased by
Current Value of Property or Lease
Firm or Owner?
1.___________________________________________________________________________________________
2. __________________________________________________________________________________________
D. Does your firm rely on any other firm for management functions or employee payroll?  Yes  No
If Yes, explain:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 9 of 15

E. Financial / Banking Information (Provide bank authorization and signature cards)
Name of bank: _________________________________
Address of bank: _______________________________ City: ______________ State: _____ Zip: __________
The following individuals are able to sign checks on this account: ______________________________________
Name of bank: _________________________________
Address of bank: _______________________________ City: ______________ State: _____ Zip: __________
The following individuals are able to sign checks on this account: ______________________________________
Bonding Information: If you have bonding capacity, identify: (a) Binder No: _________________________
(b) Name of agent/broker ______________________________ (c) Phone No: (
) ______________________
(d) Address of agent/broker: ____________________________ __________________________________________
(e) Bonding limit: Aggregate limit $ ______________________ Project limit $ _____________________
F. Identify all sources, amounts, and purposes of money loaned to your firm including 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 securing the loan, if other than the listed owner.
(Provide copies of signed loan agreements and security agreements).
Name of Source

Address of Source

Name of Person
Securing the Loan

Original
Amount

Current
Balance

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 the past two years (attach additional sheets if needed):
Contribution/Asset

Dollar Value

From Whom
To Whom
Relationship Date of
Transferred
Transferred
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.)(Provide copies of the licenses and attach additional sheets if
needed):
Name of License/Permit Holder

Type of License/Permit

Expiration
License Number
Date
and State
1.___________________________________________________________________________________________
2.___________________________________________________________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 10 of 15

I. List the three largest contracts completed by your firm in the past three years, if any:
Name of
Name/Location of
Type of Work Performed
Dollar Value of
Owner/Contractor
Project
Contract
1.___________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________

J. List the three largest active jobs on which your firm is currently working:
Name of Prime
Contractor and Project
Number

Location of
Project

Type of Work

Project
Start Date

Anticipated
Completion
Date

Dollar
Value of
Contract

_____________________________________________________________________________________
____________________________________________________________________________________________
2.

_____________________________________________________________________________________
____________________________________________________________________________________________
3.

_____________________________________________________________________________________
_____________________________________________________________________________________________

U.S. DOT Uniform DBE/ACDBE Certification Application  Page 11 of 15

AIRPORT CONCESSION (ACDBE) APPLICANTS MUST COMPLETE THIS PAGE
Concession Space

Address / Location at
Airport

Value of Property or
Lease

Fees/Lease Payments
Paid to the Airport

Provide information concerning any other airport concession businesses the applicant firm or any affiliate owns and/or
operates, including name, location, type of concession, and start date of concession
Name of Concession

Location

Type of Concession

Start Date of Concession

U.S. DOT Uniform DBE/ACDBE Certification Application  Page 12 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 SUFFICIENT
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 __________________________ (firm name) 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 (UCP) of any material
change in the information contained in the original application within 30 calendar days of such change (e.g.,
ownership, address, telephone number, 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 (DBE) or Airport Concession Disadvantaged Business
Enterprise (ACDBE). 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  Hispanic American  Native American  Asian- Pacific American
 Subcontinent Asian American Other (specify) ____________________________________________

U.S. DOT Uniform DBE/ACDBE Certification Application  Page 13 of 15

I certify 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 provided in this application and supporting documents is true
and correct.
Signature _________________________________
(DBE/ACDBE Applicant)

Executed on ___________(Date)

NOTARY CERTIFICATE
Subscribed and sworn to before me this ___day of __________, 20___.
________________________________________
Notary Public in and for the State of:
Residing at:_______________________________
________________________________________
My Commission Expires:_____________________

U.S. DOT Uniform 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
documents. The UCP to which you are applying may have additional required documents that you must also supply with
your application. Contact the appropriate certifying agency to which you are applying to find out if more is required. A
failure to supply any information requested by the UCP may result in a determination that you failed to cooperate.

All Applicants
Résumés (that include places of ownership/employment with corresponding dates), for all owners, officers, and key
personnel of the applicant firm
Personal Net Worth Statement for socially and economically disadvantaged owners (form available with this
application)
Personal Federal and State tax returns for the past 3 years, if applicable, for each disadvantaged owner
Federal and state tax returns (and requests for extensions) filed by the firm and its affiliates including all related
schedules, and firm audited financial statements (if available) for the past 3 years.
Documented proof of contributions used to acquire ownership for each owner (e.g. both sides of cancelled checks)
Your firm’s signed loan agreements, security agreements, and bonding forms
Descriptions of all real estate (including office/storage space, etc.) owned/leased by your firm and documented proof
of ownership/signed leases
List of equipment and/or vehicles owned and leased. Signed lease agreements and titles/proof of ownership
Property 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
Year-end balance sheets and income statements for the past three years (or life of firm, if less than three years); a
new business must provide a current balance sheet
All relevant licenses, license renewal forms, permits, and haul authority forms
DBE, ACDBE and SBA 8(a), SDB, MBE/WBE certifications, denials, and/or decertifications, if applicable; and
U.S. DOT appeal decisions (if any) on these actions.
Bank authorization and signatory cards
Schedule of salaries (or other remuneration) paid to all officers, managers, owners, and/or directors of the firm
List of all employees, job titles, and dates of employment.
Trust agreements held by any owner claiming disadvantaged status, if any
Partnership or Joint Venture
Original and any amended Partnership or Joint Venture Agreements
Corporation or LLC
Official Articles of Incorporation (signed by the state official)
Both sides of all corporate stock certificates and your firm’s stock transfer ledger
Shareholders’ Agreement
Minutes of all stockholders and board of directors meetings
Corporate by-laws and any amendments
Corporate bank resolution and bank signature cards
Official Certificate of Formation and Operating Agreement with any amendments (for LLCs)
Trucking Company
Documented proof of ownership of the company
Insurance agreements for each truck owned or operated by your firm
Title(s), registration certificate(s), and U.S. DOT numbers for each truck owned or operated by your firm
Suppliers
Proof of warehouse/storage facility ownership or lease arrangements
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

File Type	application/pdf
File Title	Microsoft Word - Certification Application Draft 6-7-12 version
Author	timothy.mullins
File Modified	2012-08-28
File Created	2012-08-28