Form Appendix F Appendix F Certification Application For Internal Coordination

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 ($52.47 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?
The DBE and ACDBE Programs require that all U.S. Department of Transportation (DOT) recipients of federal assistance
participate in a statewide Unified Certification Program (UCP). 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 for DOT grantees, pursuant to the eligibility
standards found in 49 C.F.R. Parts 23 and 26.
5. Where can I find more information?
U.S. DOT—https://www.civilrights.dot.gov/ (This site provides useful links to the rules and regulations governing the
DBE/ACDBE program, questions and answers, and other pertinent information)
SBA—Small 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 CFR §26.5 and the Airport Concession Disadvantaged Business
Enterprise Program as defined in 49 CFR §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, 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 2 CFR Parts 180 and 1200, Nonprocurement 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.
Paperwork Reduction Act Burden Statement

OMB CONTROL NUMBER: 2105-0510
EXPIRATION DATE: mm/dd/yyyy
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to
comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays
a currently valid OMB Control Number. The OMB Control Number for this information collection is 2105-0510. Public reporting for this
collection of information is estimated to be approximately 8 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection
of information are mandatory under the DBE regulations, 49 CFR 26.83(c). Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Office of the
Secretary of Transportation, 1200 New Jersey Ave. SE, Washington, D.C. 20590.

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
firm’s 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 firm’s fax number, if any.
(6) Enter the contact person's email address.
(7) Enter your firm’s 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 of the persons listed
has ever been denied certification as a DBE, 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. If the firm is a for
profit enterprise, 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. Identify all joint venture partners if
applicable. 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

(2)

(3)
(a)
(b)
(c)
(d)
(e)
(f)

oral agreement. Provide an explanation of any items
shared with other firms in the space provided.
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.
Check the appropriate box that indicates whether at
present or at any time in the past your firm:
ever existed under different ownership, a different
type of ownership, or a different name;
existed as a subsidiary of any other firm;
existed as a partnership in which one or more of the
partners are/were other firms;
owned any percentage of any other firm; and
had any subsidiaries of its own.
served as a subcontractor with another firm
constituting more than 25% of your firm’s receipts.

(3)

(4)

If you answered “Yes” to any of the questions in (3)(a-f),
you may be asked to explain the arrangement in detail.
(b)
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

(5)

checked “Yes,” state the name of the other business
and this owner’s function/title held in that business.
(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.
(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).
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.
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.
(1)
(2)
(3)

(4)

Identify the firm’s Officers and Board of
Directors
In the space provided, state the name, title, date of
appointment, ethnicity, and gender of each officer.
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.
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.
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 control the functions listed for the business.
Submit résumés for each owner and non-owner identified
below. State the name of the individual, title, race 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
Banking Information. State the name, City and State of
your firm’s bank. In the space provided, identify the
persons able to sign checks on this account. Provide bank
authorization and signature cards
Bonding Information. State your firm’s bonding limits (in
dollars), specifying both the 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.
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 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.

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:
________ - ____

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: ____/____/____
(5) Method of acquisition (Check all that apply):
 Started new business
 Bought existing business
 Inherited business  Secured concession
 Merger or consolidation  Other (explain) _____________________________________________________
U.S. DOT Uniform DBE / ACDBE Certification Application  Page 5 of 15

(6) Is your firm “for profit”?  Yes No→
Federal Tax ID# ________________________

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

(7) Type of Legal Business Structure: (check all that apply):
 Sole Proprietorship
 Limited Liability Partnership
 Partnership
Corporation
 Limited Liability Company  Joint Venture (Identify all JV partners __________________________)
 Applying as an ACDBE
 Other, Describe __________________________________________
(8) Number of employees: Full-time ________

Part-time ________

Seasonal ________Total _________

(Provide a list of employees, their job titles, and dates of employment, to your application).

(9) Specify the firm’s gross receipts for the last 3 years. (Submit complete copies of the firm’s Federal tax returns for
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.

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
(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) 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 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)-(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 14

Section 3: MAJORITY OWNER INFORMATION
A. Identify the majority owner of the firm holding 51% or more ownership interest.
(1) Full Name:
______________________________

(2) Title:
_________________________

(4) Home Address (Street and Number):
_____________________________________________________

(5) Gender:  Male  Female
(6) Ethnic group membership (Check all that apply):


 Hispanic
 Black
 Asian Pacific  Native American
 Subcontinent Asian
 Other (specify) ___________________
(7)

U.S. Citizenship:


 U.S. Citizen
 Lawfully Admitted Permanent Resident

(3) Home Phone #:
(
) _____ - ____________________

City:
____________________

State:
________

Zip:
_________ - ______

(8) Number of years as owner: _______
(9) Percentage owned: __________ %
Class of stock owned: _________
Date acquired ________________
(10) Initial investment to Type
Dollar Value
acquire ownership
Cash
$
interest in firm:
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 supervisory 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
 Yes  No
Identify the 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: ___________________________________________

interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)

(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 14

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:
_________________________

(4) Home Address (Street and Number):
_____________________________________________________

(3) Home Phone #:
(
) _____ - ____________________

City:
____________________

State:
________

Zip:
_________ - ______

(5) Gender:  Male  Female

(8) Number of years as owner: _______
(9) Percentage owned: _________ %
Class of stock owned: ________
(6) Ethnic group membership (Check all that apply)
Date acquired _______________

 Hispanic
 Black
(10) Initial investment to Type
Dollar Value
 Asian Pacific  Native American
acquire
ownership
Cash
$
 Subcontinent Asian
interest in firm:
Real Estate $
 Other (specify) ___________________
Equipment $
Other
$
(7) U.S. Citizenship:

 U.S. Citizen
 Lawfully Admitted Permanent Resident

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 supervisory 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 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: __________________________________________
(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: (Please attach extra sheets, if needed): _________________
____________________________________________________________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 8 of 14

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)
(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 of Owners, Officers, Directors, Managers, and Key Personnel
1. (Identify your firm’s management personnel who control your firm in the following areas (Attach separate sheets as needed).
A= Always
F = Frequently

S = Seldom
N = Never

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 (billing,
accounts receivable/payable, etc.)
Hires and fires management staff
Hire and fire field staff or crew
Designates profits spending or investment
Obligates business by contract/credit
Purchase equipment
Signs business checks

Majority Owner (51% or more)
Name: _______________________
Title: ________________________
Percent Owned:_______
A
F
S
N

Minority Owner (49% or less)
Name: ____________________________
Title: _____________________________
Percent Owned:_______
A
F
S
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
N

U.S. DOT Uniform DBE/ACDBE Certification Application  Page 9 of 14

2. Complete for all Officers, Directors, Managers, and Key Personnel who control the following functions for
the firm. (Attach separate sheets as needed).
A= Always
F = Frequently

S = Seldom
N = Never

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 (billing,
accounts receivable/payable, etc.)
Hires and fires management staff
Hire and fire field staff or crew
Designates profits spending or investment
Obligates business by contract/credit
Purchase equipment
Signs business checks

Officer/Director/Manager/Key Personnel
Name: ________________________
Title: _________________________
Race and Gender:_______________
Percent Owned:_________________
A
F
S
N

Officer/Director/Manager/ Key Personnel
Name: ________________________
Title: _________________________
Race and Gender:_______________
Percent Owned:_________________
A F
S
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
N

A
A
A
A
A
A

F
F
F
F
F
F

S
S
S
S
S
S

N
N
N
N
N
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.,
If Yes, describe the nature of
the business relationship:_________________________________________________________________________

ownership interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)

_______________________________________________________________________________________________________

C. Inventory: Indicate your firm’s inventory in the following categories (Please attach additional sheets if needed):
1. Equipment and Vehicles
Make and Model

Current
Owned or Leased
Used as collateral?
Where is item stored?
Value
by Firm or Owner?
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
5. __________________________________________________________________________________________
6. __________________________________________________________________________________________
7. __________________________________________________________________________________________
8. __________________________________________________________________________________________
9. __________________________________________________________________________________________
2. Office Space
Street Address
Owned or Leased by Firm or Owner?
Current Value of Property or Lease
____________________________________________________________________________________________
____________________________________________________________________________________________
___________________________________________________________________________________________
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 10 of 14

3. 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?
____________________________________________________________________________________________
____________________________________________________________________________________________
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: _________________________________ City and State: _________________________________
The following individuals are able to sign checks on this account: ______________________________________
Bonding Information: 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 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 guaranteeing 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
Guaranteeing 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.)(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 14

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

1. ______________________________________________________________________________________
_______________________________________________________________________________________________
2. ______________________________________________________________________________________
_______________________________________________________________________________________________
3. ______________________________________________________________________________________
_______________________________________________________________________________________________

AIRPORT CONCESSION (ACDBE) APPLICANTS ONLY MUST COMPLETE THIS SECTION
Identify the following information concerning the ACDBE applicant firm:
Concession Space
Address / Location at
Value of Property or
Airport
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 14

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
__________________________________________ 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  Hispanic American
 Native American  Asian-Pacific American
 Subcontinent Asian American  Other (specify)
____________________________________________
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)
NOTARY CERTIFICATE

U.S. DOT Uniform DBE/ACDBE Certification Application  Page 13 of 14

__________
(Date)

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 employment with
corresponding dates), for all owners, officers, and key
personnel of the applicant firm
Personal Net Worth Statement for each socially and
economically disadvantaged owners comprising 51% or more
of the ownership percentage of the applicant firm.
Personal Federal tax returns for the past 3 years, if
applicable, for each disadvantaged owner
Federal tax returns (and requests for extensions) filed by
the firm and its affiliates with related schedules, for the past 3
years.
Documented proof of contributions used to acquire
ownership for each owner (e.g., both sides of cancelled
checks)
Signed loan and security agreements, 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 decertifications, 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
officers, 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
arrangements

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)
Optional Documents to Be Provided on Request
The UCP 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
Audited financial statements (if available)
Personal Federal Tax returns for the past 3 years, if
applicable, for other disadvantaged owners of the firm.
Trust agreements held by any owner claiming
disadvantaged 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

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(s)
Minutes of all stockholders and board of directors meetings
U.S. DOT Uniform DBE/ACDBE Certification Application  Page 14 of 14