Bidders List Form

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OMB CONTROL NUMBER: 2105-0
EXPIRATION DATE: (pend

Paperwork Reduction Act Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor sha
person be subject to a penalty for failure to comply with a collection of information subject to
requirements of the Paperwork Reduction Act unless that collection of information displays a curre
valid OMB Control Number. The OMB Control Number for this information collection is 2105-0586. Pu
reporting for this collection of information is estimated to be approximately 8 hours per response, includ
the time for reviewing instructions, searching existing data sources, gathering and maintaining the d
needed, completing and reviewing the collection of information.
All responses to this collection of information are mandatory under 49 CFR § 26.11; the nature and ex
of confidentiality to be provided, if any under 49 CFR §§ 26.109(b). Send comments regarding this bur
estimate or any other aspect of this collection of information, including suggestions for reducing
burden to: Information Collection Clearance Officer, (your agency name and address), Washington, D
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
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 Enterp
(DBE) and Airport Concession Disadvantaged Business Enterprise (ACDBE) inquiries and adjudic
appeals.
ROUTINE USE(S): In accordance with DOT’s system of records notice, DOT/ALL–24 Departmental Of
of Civil Rights System, 76 FR 71108 (Nov. 16, 2011), the information provided may be disclosed to the
S. Department of Justice, including United States Attorney’s Offices, or other Federal agency conduc
litigation or in proceedings before any court, adjudicative or administrative body, when it is necessar
the litigation and one of the following is a party to the litigation or has an interest in such litigation
comprehensive list of routine uses can be found in DOT/ALL 24 and DOT’s General Statement of Rou
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.

Bidders List - 26.11 (c)
Firm name
Name:

Firm Address
Street:
City:
State:
Zip Code:

ACDBE / non-ACDBE
ACDBE
Non-ACDBE

Applicable NAICS Code
NAICS Code:

Age of the firm
No. of Years:

Annual gross receipts of the firm.
< $1,000,000
$1,000,000 - $3,000,000
$3,000,000 - $6,000,000
$6,000,000 - $10,000,000
$10,000,000 - $20,000,000
> $20,000,000