Uniform Certification Application

OMB APPROVAL NO: 2105-0586

EXPIRATION DATE: (pending)

U.S. Department of Transportation

OMB CONTROL NUMBER: 2105-0586
EXPIRATION DATE: (pending)

Paperwork Reduction Act Burden Statement

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 2105-0586. Public reporting for this collection of information is estimated to be approximately 35 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 49 CFR §§ 23.39 and 26.83; the nature and extent of confidentiality to be provided, if any under 49 CFR §§ 26.83(d) and 26.109(b). 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, (your agency name and address), Washington, D.C. 20590.

Privacy Act Statement (5 U.S.C. § 552a, as amended): 

AUTHORITY: 42 U.S.C. 2000d et seq., § 12101 et seq., 42 U.S.C. 6101 et seq.; 29 U.S.C. 794, 749d; 49 U.S.C. 47113; 42 U.S.C. 12101; 49 CFR Part 23; 49 CFR Part 26, and Executive Order 13160.

PURPOSE(S): DOT will use the information collected to respond to Disadvantaged Business Enterprise (DBE) and Airport Concession Disadvantaged Business Enterprise (ACDBE) inquiries and adjudicate appeals.

ROUTINE USE(S):  In accordance with DOT’s system of records notice, DOT/ALL–24 Departmental Office of Civil Rights System, 76 FR 71108 (Nov. 16, 2011), the information provided may be disclosed to the U. S. Department of Justice, including United States Attorney’s Offices, or other Federal agency conducting litigation or in proceedings before any court, adjudicative or administrative body, when it is necessary to the litigation and one of the following is a party to the litigation or has an interest in such litigation. A comprehensive list of routine uses can be found in DOT/ALL 24 and DOT’s General Statement of Routine uses, 75 FR 82138 (Dec. 29, 2010). 77 FR 42796 (July 20, 2012), 84 FR 55222 (Oct. 15, 2019).

DISCLOSURE: Provision of the requested information is voluntary; however, failure to furnish the requested information may result in the denial of a DBE or ACDBE application and an inability of the Department to process an appeal or inquiry from any party.

UNIFORM CERTIFICATION APPLICATION DISADVANTAGED BUSINESS ENTERPRISE (DBE)/AIRPORT CONCESSIONS DISADVANTAGED BUSINESS ENTERPRISE (ACDBE) PROGRAMS 49 CFR Parts 23 and 26

1. Should I apply?

You may be eligible to participate in the DBE/ACDBE programs if:

1. The firm is a for-profit business that performs or seeks to perform transportation-related work (or an airport concession activity) for a recipient of Federal Aviation Administration, Federal Highway Administration, or Federal Transit Administration funds.

• The firm is at least 51% owned and controlled by a socially and economically disadvantaged individual(s) who is a U.S. citizen(s) or lawfully admitted permanent U.S. resident(s).

  • Refer to § 26.5 of 49 CFR Part 26 for the definition of “socially and economically disadvantaged individual.”

  • Refer to https://www.transportation.gov/DBEPNW for “personal net worth cap.”

  • Refer to § 26.69 and 26.70 of 49 CFR Part 26 to determine whether you meet the ownership and control requirements.

• The firm meets the Small Business Administration’s (SBA) and the DBE/ACDBE program’s size standards at https://www.transportation.gov/DBEsizestandards

It is the applicant firm’s responsibility to provide sufficient evidence to demonstrate that, more likely than not, it meets all eligibility requirements.

2. How do I apply?

Firms applying for DBE/ACDBE certification in their home state, i.e., the state in which the firm maintains its principal place of business, must submit to a certifying agency in their home state a completed Uniform Certification Application and all required documents (see attached checklist) and participate in an on-site interview. Failure to timely submit documents may result in delayed processing or denial of your application.

Firms already certified as a DBE/ACDBE in their home state do not have to complete this form. Section 26.85 of 49 CFR Part 26 explains the process for obtaining certification in additional states, i.e., interstate certification.

3. Where can I send my application?

Transportation agencies in each state perform DBE and ACDBE certification functions. DOT’s website has a table of certifying agency contacts at https://www.transportation.gov/DBEPOC

Click on the link to access contact information for your state/territory and obtain details on how to submit your application.

4. What happens after I apply?

A transportation agency in your state that performs certification functions will contact you.

5. Where can I find more information?

Visit the USDOT website at https://www.transportation.gov/DBE for links to the DBE/ACDBE program rules and regulations (including those for interstate certification), answers to frequently asked questions, points of contact, and more.

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.

Under 49 CFR § 26.107, 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, No procurement Suspension and Department, 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 USC 1001, which prohibits false statements in federal programs

INSTRUCTIONS

NOTE: All participating firms must be for-profit enterprises with current business operations. If your firm is not for profit, or is not conducting business, 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

1. Basic Contact Information

1. Enter the name and title of the person completing this application 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 (if any) or similar document.

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 address, 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.

2. Prior/Other Certifications and Applications

Indicate whether your firm or any firms owned by the persons listed has ever been denied certification as a DBE/ACDBE, 8(a), or Small Disadvantaged Business (SDB) firm, or state and local MBE/WBE firm. Indicate if the firm has ever been decertified from one of these programs. Indicate if the application was withdrawn or whether the firm was debarred, suspended, or otherwise had its bidding privileges denied or restricted by any state or local agency, or Federal entity. If your answer is yes, identify the name of the agency, and explain fully the nature of the action in the space provided. Indicate if you have ever appealed this decision to the Department and if so, attach a copy of USDOT’s final agency decision(s).

Section 2: GENERAL INFORMATION

1. 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 states’ online directories of certified firms.

2. If you know the appropriate North American Industry Classification System (NAICS) code for the type(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 (if any) or similar document.

4. State the date each person became a firm owner.

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.

5. Check the appropriate box that indicates whether your firm is “for profit.” If you checked “No,” then you do NOT qualify for the DBE/ACDBE program and should not complete this application. All participating firms must be for-profit enterprises. Provide the Federal Tax ID number as stated on your firm’s Federal tax return.

6. Check the appropriate box that describes the type of legal business structure of your firm, as indicated in your firm’s Articles of Incorporation or similar document. If you checked “Other,” briefly explain in the space provided.

7. 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.

8. Specify the firm’s gross receipts for each of the past five years, as stated in your firm’s filed federal tax returns. You must submit all portions of federal tax returns related to gross receipts and signature pages, as filed. If there is no federal tax return yet filed for the most recent taxable year, you may provide an income statement signed by a CPA who attests to its accuracy and completeness. If there are any affiliates or subsidiaries of the applicant firm or owners, you must provide documentation these firms’ gross receipts also as described above. Affiliation is defined in 49 C.F.R. §26.5 and 13 C.F.R. Part 121.

2. Relationships and Dealings with Other Businesses

1. Check the appropriate box that indicates whether your firm is co-located at any of its business locations, or whether your firm shares a telephone number(s), a post office box, any office space, a yard, warehouse, other facilities, any equipment, financing, or any office staff and/or employees with any other business, organization or entity of any kind. If you answered “Yes,” then specify the name of the other firm(s) and fully explain the nature of your relationship with these other businesses by identifying the business or person with whom you have any formal, informal, written, or oral agreement. Provide an explanation of any items shared with other firms in the space provided.

2. Check the appropriate box indicating whether any other firm currently has or had an ownership interest in your firm at present or at any time in the past. If you checked yes, please explain.

3. Check the appropriate box that indicates whether at present or at any time in the past your firm:

1. ever existed under different ownership, a different type of ownership, or a different name;

2. existed as a subsidiary of any other firm;

3. existed as a partnership in which one or more of the partners are/were other firms;

4. owned any percentage of any other firm; and

5. had any subsidiaries of its own.

6. served as a subcontractor with another firm constituting more than 25% of your firm’s receipts.

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

Section 3: MAJORITY OWNER INFORMATION

Identify all individuals or holding companies with any ownership interest in your firm, providing the information requested below (if your firm has more than one owner, provide completed copies of this section for each owner):

1. Identify the majority owner of the firm holding 51% or more ownership interest:

1. Enter the full name of the owner.

2. Enter the owner’s title or position.

3. Give the owner’s phone number.

4. Enter the owner’s home (street) address.

5. Indicate the 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 the firm may not rely on this owner’s social and economic disadvantaged status for DBE certification eligibility.

8. Enter the number of years 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, gift and/or other investment. Describe how the owner acquired the business and attach documentation substantiating this investment.

11. List additional investments.

2. Additional Owner Information

1. Describe the familial relationship of this owner to each other owner of your firm and employees.

2. Indicate whether this owner performs a management or supervisory function for any other business. If you checked “Yes,” state the name of the other business and this owner’s function/title held in that business.

3. (a) Check the appropriate box that indicates whether this owner owns or works for any other firm(s) that has any relationship with your firm. If you checked “Yes,” identify the name of the other business, the nature of the business relationship, and the owner’s function at the firm.

(b) If the owner works for any other firm, non-profit organization, or is engaged in any other activity more than 10 hours per week, please explain this activity.

4. (a) Provide the personal net worth of the owner claiming social and economic disadvantage in the space provided. Complete and attach the accompanying “Personal Net Worth Statement for DBE/ACDBE Program Eligibility” with your application. Complete this section and accompanying statement only for each owner claiming to be socially and economically disadvantaged.

(b) Check the appropriate box that indicates whether any trust has been created for the benefit of the disadvantaged owner(s). If you answered “Yes,” you may be asked to provide a copy of the trust instrument.

5. Check the appropriate to indicate whether any of your immediate family members, managers, or employees, own, manage, or are associated with another company. Immediate family member is defined in 49 C.F.R. §26.5. If you answered “Yes,” provide the name of each person, your relationship to that person, , the name of the company, the type of business, and whether that person owns or manages the company.

Section 4: CONTROL

1. Identify the firm’s Officers and Board of Directors

1. In the space provided, state the name, title, date of appointment, group membership, and gender of each officer.

2. In the space provided, state the name, title, date of appointment, group membership , 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 such individual by name and , provide the name of the other business in which that individual is involved, and describe the nature of that individual’s role in the other business.

4. Check the appropriate box that indicates whether any of your firm’s officers and/or directors listed above own or work for any other firm(s) that has a relationship with your firm. (e.g., ownership interest, shared office space, financial investments, equipment leases, personnel sharing, etc.) If you answered “Yes,” identify the name of the firm, the individual’s name, and the nature of the individual’s relationship with that other firm.

2. Duties of Owners, Officers, Directors, Managers and Key Personnel

Specify the roles of the majority and minority owners, directors, officers, and managers, and key personnel who are responsible for the functions listed for the firm. Submit résumés for each owner and non-owner identified below. State the name of the individual, title, race 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.

3. 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.

4. 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.

5. Financial / Banking Information

State the name, city and state of your firm’s bank. Identify the individuals authorized to sign checks on this account. Provide bank documentation that shows all individuals who are authorized to sign checks on the firm’s behalf.

Bonding Information. State your firm’s bonding limits both aggregate and project limits.

6. 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

7. 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.

8. 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 identify the state that issued the license or permit. Attach copies of licenses, license renewal forms, permits, and haul authority forms.

9. 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.

10. Largest active jobs on which your firm is currently working.

For each active job listed, state the name of the prime contractor and the project number, the location, the type of work performed, the project start date, the anticipated completion date, and the dollar value of the contract.

Section 5: AIRPORT CONCESSION (ACDBE) APPLICANTS

Complete the entries in this section if you are applying for ACDBE certification. Indicate in Section A if you operate a concession at the airport, and/or supply a good or service to an airport concessionaire. Indicate in Section B whether the applicant firm owns or operates any off-airport locations, providing the type of business, lease information, address/location, and annual gross receipts generated. Provide similar information in section C for any airport concession locations the firm currently owns or operates. If the applicant firm has any affiliates, provide the requested information in Section D. Indicate whether the ACDBE firm is participating in any joint ventures, and if so, include the original and any amended joint venture agreements.

DECLARATION & SIGNATURE

The Declaration of Eligibility must accompany your application. Carefully read the attached declaration in its entirety. Fill in the required information for each blank space, and sign and date the declaration.

If you are already certified as a DBE/ACDBE, you do NOT have to complete this application for other states. Refer to § 26.85 of 49 CFR Part 26 for details about the interstate certification process.

Section 1: CERTIFICATION INFORMATION

A. Basic Contact Information:

My firm is applying for certification as DBE ACDBE

(1) Contact person’s name 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 (No P.O. Box): City: County/Parish: State: Zip:

B. Prior/Other Certifications and Applications

(10) 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 sheets if necessary. This description may be used in states’ online databases and directories of certified firms.

(2) NAICS Codes for this line of work include:

(3) This firm was established on:

(4) Is the firm “for profit”? _ Yes Federal Tax ID# ________________________ __ No STOP! If the firm is NOT for-profit, then the firm does NOT qualify for this program and should not fill out this application.

(5) Type of Legal Business Structure: (check all that apply):

___Sole Proprietorship

___Limited Liability Partnership

___Partnership

___Corporation

___Limited Liability Company

___Other (describe): __________________________________________

(6) Number of employees: Full-time Part-time Seasonal Total

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

(7) Specify the firm’s gross receipts for the last 5 years. (Submit complete copies of the firm’s federal tax returns for each year. You may provide gross receipt information for the past 5 years. 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 $__________

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. Provide details about the shared items.

(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).

Section 3: MAJORITY OWNER INFORMATION

A. Identify the owner of the firm holding 51% or more ownership interest in the firm.

(1) Full Name:

(2) Title:

(3) Home Phone #:

(4) Home Address (Street and Number) City State Zip

(5) Gender: __ Male __ Female Other:

(6) Group membership (Check all that apply):

__ Black American

__ Hispanic American

__ Asian-Pacific American

__ Native American

__ Subcontinent Asian American

__ Other:

(7) Residency Status:

__ U.S. Citizen

__ Lawfully Admitted Permanent Resident

(8) Number of years as owner:

(9) Percentage owned: (a) Class of stock owned (if applicable):

(b) Date acquired

(10) Initial investment to acquire ownership in firm: Type Dollar Value

Cash $

Real Estate $

Equipment $ Other $

Describe how the majority owner acquired ownership of the firm:

___ Started business myself

___ Received it as a gift from

___ Bought it from:

___ Inherited it from:

___ Other:

(Attach documentation substantiating your investment and method of acquisition)

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

If yes, 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 engage in any other activity more than 10 hours per week? __ Yes __ No If yes, identify this activity:

(4)(a) What is the Personal Net Worth (PNW) of this disadvantaged owner?

(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, owners, directors, officers, managers, or employees own, manage, or have any association 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):

Section 3: ADDITIONAL OWNER INFORMATION

A. Identify all individuals, firms, or companies that hold LESS THAN 51% ownership interest in the firm (Attach separate sheets for each additional owner)

(1) Full Name:

(2) Title:

(3) Home Phone #:

(4) Home Address (Street and Number) City State Zip

(5) Gender: __ Male __ Female Other:

(6) Group membership (Check all that apply):

__ Black American

__ Hispanic American

__ Asian-Pacific American

__ Native American

__ Subcontinent Asian American

__ Other:

(7) Residency Status:

__ U.S. Citizen

__ Lawfully Admitted Permanent Resident

(8) Number of years as owner:

(9) Percentage owned: (a) Class of stock owned (if applicable):

(b) Date acquired

(10) Initial investment to acquire ownership in firm: Type Dollar Value

Cash $

Real Estate $

Equipment $ Other $

Describe how the owner acquired ownership:

___ Started business myself

___ Received it as a gift from

___ Bought it from:

___ Inherited it from:

___ Other:

(Attach documentation substantiating your investment and method of acquisition)

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

If yes, 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 engage in any other activity more than 10 hours per week? __ Yes __ No If yes, identify this activity:

(4)(a) What is the Personal Net Worth (PNW) of this disadvantaged owner?

(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, owners, directors, officers, managers, or employees own, manage, or have any association 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):

Section 4: CONTROL

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

	Name	Title	Date Appointed	Ethnicity	Gender
(1) Officers of the Company	(a)
	(b)
	(c)
	(d)
(2) Board of Directors	(a)
	(b)
	(c)
	(d)

(3) Do any of the persons listed above perform a management or supervisory function for any other business?

__ Yes __ No If yes, identify for each:

Person: Title:

Business: Function:

Person: Title:

Business: Function:

(4) Do any of the persons listed in Section A above own or work for any other firm(s) that has a relationship with this firm? (e.g., ownership interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.)

__ Yes __ No If Yes, identify for each:

(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. Complete for all owners who are responsible for the following functions: (Attach separate sheets as needed)

		Majority Owner (51% or more)				Minority Owner (49% or less)
A= Always F = Frequently	S = Seldom N = Never	Name: _______________________ Title: ________________________ Percent Owned:_______				Name: ____________________________ Title: _____________________________ Percent Owned:_______
Sets policy for company direction/scope of operations		A	F	S	N	A	F	S	N
Bidding and estimating		A	F	S	N	A	F	S	N
Major purchasing decisions		A	F	S	N	A	F	S	N
Marketing and sales		A	F	S	N	A	F	S	N
Supervises field operations		A	F	S	N	A	F	S	N
Attend bid opening and lettings		A	F	S	N	A	F	S	N
Perform office management (billing, accounts receivable/payable, etc.)		A	F	S	N	A	F	S	N
Hires and fires management staff		A	F	S	N	A	F	S	N
Hire and fire field staff or crew		A	F	S	N	A	F	S	N
Designates profits spending or investment		A	F	S	N	A	F	S	N
Obligates business by contract/credit		A	F	S	N	A	F	S	N
Purchase equipment		A	F	S	N	A	F	S	N
Signs business checks		A	F	S	N	A	F	S	N

Do any of the persons listed in B1 or B2 perform a management or supervisory function for any other business? If Yes, identify the person, the business, and their title/function:

Do any of the persons listed above own or work for any other firm(s) that has a relationship with this firm? (e.g., ownership interest, shared office space, financial investments, equipment, leases, personnel sharing, etc.) If Yes, describe the nature of the business relationship:

C. Inventory: Indicate your firm’s inventory in the following categories (Please attach additional sheets if needed):

1. Equipment and Vehicles

	Make and Model	Current value	Owned or leased by firm or owner?	Used as collateral?	Where is item stored?

2. Office Space

Address (Street and Number) City State Zip

Owned or Leased by Firm or Owner? Yes No (if yes, provide details):

Current Value of Property or Lease:

3. Storage Space (Provide signed lease agreements for the properties listed)

Address (Street and Number) City State Zip

Owned or Leased by Firm or Owner? Yes No (if yes, provide details):

Current Value of Property or Lease:

D. Does your firm rely on any other firm for management functions or employee payroll? Yes _No

E. Financial/Banking Information (Provide bank authorization and signature cards)

Name of bank: City and State:

The following individuals are authorized to sign checks on this account:

Name of bank: City and State:

The following individuals are authorized to sign checks on this account:

Name of bank: City and State:

The following individuals are authorized 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 he owner or 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

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 Transferred	To Whom Transferred	Relationship	Date of Transfer

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

I. List the three largest contracts completed by your firm in the past three years, if any:

	Name of Owner/Contractor	Name/Location of Project	Type of Work Performed	Dollar Value of Contract

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

Additional Information:

SECTION 5 - AIRPORT CONCESSION

(ACDBE APPLICANTS ONLY)

A. I am applying for ACDBE certification to: (check all that apply)

___ Operate a concession at an airport ___ Supply a good or service to an airport concessionaire

B. Does the applicant firm own/operate any off-airport locations? ___ Yes ___ No (if yes, identify the following):

Type of Business  (e.g., F&B, News & Gift, Retail, Duty Free, Advertising, etc.)	Lease Term (years)	Lease Start Date	Address / Location	Annual Gross Receipts Generated

C. Does the applicant firm currently own/operate any airport concession locations? □ Yes □ No (If yes, supply the following information):

Airport Name	Concession Type  (e.g., F&B, News & Gift, Retail, Duty Free, Advertising, etc.)	Number of Leases	Number of Locations	Annual Gross Receipts Generated	Lease Type (e.g. Direct Lease, Subcontract Management Agreement, etc. enter all that apply to the leases listed)

D. Does the applicant firm have any affiliates? __ Yes __ No If Yes, provide the following information concerning any locations owned/operated by affiliate firms.

Airport Name	Concession Type (e.g., F&B, News & Gift, Retail, Duty Free, Advertising, etc.)	Number of Leases	Number of Locations	Annual Gross Receipts Generated	Lease Type (e.g. Direct Lease, Subcontract Management Agreement, etc. enter all that apply to the leases listed)

E. Is the ACDBE applicant firm a participant in any joint ventures? ___ Yes ___ No   If Yes, attach all original and any amended Joint Venture Agreements and any amendments to the agreements.

Airport Name	Concession Type (e.g., F&B, News & Gift, Retail, Duty Free, Advertising, etc.)	Number of Leases	Number of Locations	Annual Gross Receipts Generated	Lease Type (e.g. Direct Lease, Subcontract Management Agreement, etc. enter all that apply to the leases listed)

E. Is the ACDBE applicant firm a participant in any joint ventures? __ Yes __ No   If Yes, attach all original and any amended Joint Venture Agreements and any amendments to the agreements.

DECLARATION OF ELIGIBILITY

This form must be signed by each owner upon whose disadvantaged status the firm relies for certification.

A FALSE STATEMENT OR MATERIAL OMISSION MADE IN CONNECTION WITH THIS SUBMISSION IS SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION, DECERTIFICATION, OR SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON OR ENTITY MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES AVAILABLE UNDER FEDERAL AND STATE LAW.

I (full name printed), declare under penalty of perjury that I am (title) of the firm , all of the foregoing information and statements submitted for eligibility are true, correct, and complete to the best of my knowledge. 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 material is for the purpose of inducing certification 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 material, and I authorize such agency to contact any entity named in certification material, 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 or decertification.

If awarded a contract, subcontract, concession lease or sublease, as detailed in § 26.55, 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 my firm’s (1) commercially useful function (CUF) performed on the project or concession lease; (2) payments; and (3) proposed changes, if any, to the foregoing arrangements.

I agree to notify the certifying agency of a material change in circumstances that affects my firm’s eligibility within 30 days of its occurrence, explain the change fully, and include a duly executed Declaration of Eligibility (this form) with the notice.

I acknowledge and agree that any misrepresentations in certification materials or in records pertaining to a contract or subcontract will be grounds for terminating any contract or subcontract which may be awarded; denial or decertification; suspension and debarment; and for initiating action under federal and/or state law.

I declare 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 declare 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):

_ Women _ Black American _ Hispanic American

_ Native American _ Asian-Pacific American

_ Subcontinent Asian American

_ Other pursuant to 49 CFR § 26.67(d).

I declare 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 declare that my personal net worth does not exceed the DBE program’s limit posted on https://www.transportation.gov/DBEPNW, 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.

Pursuant to 28 USC § 1746:

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Executed on ( ___(Date) )

Signature

(owner)

UNIFORM CERTIFICATION APPLICATION

SUPPORTING DOCUMENTS CHECKLIST

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 who the applicant firm relies upon to satisfy the Regulation’s 51% ownership requirement.

Personal Federal tax returns for the past 3 years, if applicable, for each disadvantaged owner.

Federal tax returns (and requests for extensions) filed by the firm and its affiliates with related schedules, for the past 5 years, or the number of years in business, if fewer.

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 decertification’s, if applicable; and any U.S. DOT 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.

Partnership or Joint Venture

Original and any amended Partnership or Joint Venture Agreements.

Corporation or LLC

Official Certificate of Formation and current Operating/Shareholder Agreement, if any.

Official Articles of Incorporation (signed by the state official).

􀂉 Both sides of all corporate stock certificates and your firm’s stock transfer ledger.

Minutes of stockholder, member, partner, and board of director’s meetings, if any.

Company by-laws and any amendments.

Evidence of signature authority on the firm’s bank accounts.

Failure to provide any of these required documents that are applicable to your firm’s application may result in denial of your application.

Optional Documents to Be Provided on Request

The certifying agency to which you are applying may require the submission of the following documents. If requested to provide any of these documents, you must supply them with your application or at the on-site visit. Failure to do so may result in denial of your application.

Proof of citizenship or lawful permanent residence

Insurance agreements for each truck owned or operated by your firm.

Audited financial statements (if available)

Trust agreements held by any owner claiming disadvantaged status.

Suppliers

List of product lines carried and list of distribution equipment owned and/or leased.

U.S. DOT Uniform DBE / ACDBE Certification Application · Page 1 of 17