UNIFORM CERTIFICATION APPLICATION DISADVANTAGED BUSINESS ENTERPRISE (DBE)/AIRPORT CONCESSIONS ISADVANTAGED BUSINESS ENTERPRISE (

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OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

Paperwork Reduction Act Burden Statement

OMB CONTROL NUMBER: 2105-0586
EXPIRATION DATE: (05/31/2027)

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.

DBE/ACDBE Uniform Certification Application • Page 1 of 17

U.S. Department of Transportation

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

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 26.71 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 (generally the state in which the firm maintains its principal
place of business), must submit to a certifying agency in that 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 do not have to complete this form. Section 26.85 of 49 CFR Part
26 explains the process for obtaining certification in additional jurisdictions, 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-businesssize-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

DBE/ACDBE Uniform Certification Application • Page 2 of 19

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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
A. Basic Contact Information
(1) 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.
(2) Enter the name and title of the person completing
this application who will serve as your firm's
contact for this application.
(3) Enter the legal name of your firm, as indicated in
your firm’s Articles of Incorporation (if any) or
similar document.
(4) Enter the primary phone number of your firm.
(5) Enter a secondary phone number, if any.
(6) Enter your firm’s fax number, if any.
(7) Enter the contact person's email address.
(8) Enter your firm’s website address, if any.
(9) Enter the street address of the firm where its
offices are physically located (not a P.O. Box).
(10) Enter the mailing address of your firm, if it is
different from your firm’s street address.
B. 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
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 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. State the date on which
your firm was established as stated in your
firm’s Articles of Incorporation (if any) or
similar document.
(3) 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.
(4) 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.
(5) 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.
(6) 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.
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

DBE/ACDBE Uniform Certification Application • Page 3 of 19

U.S. Department of Transportation

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:
(a) ever existed under different ownership, a
different type of ownership, or a different
name;
(b) existed as a subsidiary of any other firm;
(c) existed as a partnership in which one or
more of the partners are/were other firms;
(d) owned any percentage of any other firm;
and
(e) had any subsidiaries of its own.
(f) 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)(af), 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):
A. 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) 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/ACDBE certification eligibility.
(6) Enter the number of years this owner has been
an owner of your firm.
(7) Indicate the percentage of the total ownership this
person holds and the date acquired, including (if
appropriate), the class of stock owned.
(8) 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

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

how the owner acquired the business and attach
documentation substantiating this investment.
(9) List additional investments.
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 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, nonprofit 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
A. Identify the firm’s Officers and Board of
Directors
(1) In the space provided, state the name, title, and
date of appointment of each officer.
(2) In the space provided, state the name, title, and
date of appointment of members 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

DBE/ACDBE Uniform Certification Application • Page 4 of 19

U.S. Department of Transportation

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.
B. 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, 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?

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

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

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.
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 identify the state that issued 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

DBE/ACDBE Uniform Certification Application • Page 5 of 19

U.S. Department of Transportation

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

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 (or will 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.

DBE/ACDBE Uniform Certification Application • Page 6 of 19

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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:
Is the firm “for profit”?
Yes Federal Tax ID#
No. STOP! (If the firm is NOT forprofit, then the firm does NOT qualify for this program and should not fill out this application.)
Is your firm applying for certification as
Is your firm Tribally-owned?
No
(Check relevant designation):

DBE

ACDBE

Yes Name _______________

Alaska Native Corporation (ANC) STOP! (Please contact the certifier. You do not need to complete this application.
See 49 CFR 26.63(c)(2)(ii).)
Federally or State-recognized Tribe, band, nation
Native Hawaiian Organization
(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?

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.)

DBE/ACDBE Uniform Certification Application • Page 7 of 19

U.S. Department of Transportation

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

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) Type of Legal Business Structure: (check all that apply):
Sole Proprietorship
Limited Liability Partnership
Partnership
Corporation
Limited Liability Company
Other (describe):
(5) Number of employees: Full-time
Part-time
Seasonal
Total 0
(Provide a list of employees, their job titles, and dates of employment, to your application).
(6) 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
Year
Year
Year
Year

Gross Receipts of Applicant Firm $
Gross Receipts of Applicant Firm $
Gross Receipts of Applicant Firm $
Gross Receipts of Applicant Firm $
Gross Receipts of Applicant Firm $

Gross Receipts of Affiliate Firms $
Gross Receipts of Affiliate Firms $
Gross Receipts of Affiliate Firms $
Gross Receipts of Affiliate Firms $
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?

DBE/ACDBE Uniform Certification Application • Page 8 of 19

Yes

No

OMB APPROVAL NO: 2105-0586
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U.S. Department of Transportation

(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?
(d) Owned any percentage of any other firm?
(e) Had any subsidiaries?

Yes

Yes

Yes

No

No

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).

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OMB APPROVAL NO: 2105-0586
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U.S. Department of Transportation

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) Residency Status:
U.S. Citizen
Lawfully Admitted Permanent Resident
(6) Number of years as owner:
(7) Percentage owned:
(8) Class of stock owned (if applicable):
(9) 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?
If yes, identify: Name of Business:
Function/Title:

Yes

No

(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):

DBE/ACDBE Uniform Certification Application • Page 10 of 19

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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) Residency Status:
U.S. Citizen
Lawfully Admitted Permanent Resident

(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)

(6) Number of years as owner:
(7) Percentage owned:
(8) Class of stock owned (if applicable):
(9) Date acquired
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?
If yes, identify: Name of Business:
Function/Title:

Yes

No

(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

DBE/ACDBE Uniform Certification Application • Page 11 of 19

U.S. Department of Transportation

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

(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):

DBE/ACDBE Uniform Certification Application • Page 12 of 19

U.S. Department of Transportation

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

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

Title

Date
Appointed

(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:

Firm Name:

Person:

Nature of Business Relationship:

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

DBE/ACDBE Uniform Certification Application • Page 13 of 19

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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

S = Seldom

Majority Owner (51% or more)
Name:

F = Frequently

N = Never

Title:

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

Minority Owner (49% or less)
Name:
Title:

Percent Owned:
A
F
S

N

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

F
F
F

S
S
S

N
N
N

A
A
A

F
F
F

S
S
S

N
N
N

A
A
A

F
F
F

S
S
S

N
N
N

A
A
A

F
F
F

S
S
S

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.,
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)
Owned or Leased by Firm or Owner? Yes

City
No (if yes, provide details):

State

Zip

City
State
No (if yes, provide details):

Zip

Current Value of Property or Lease:
3. Storage Space (Provide signed lease agreements for the properties listed)
Address (Street and Number)
Owned or Leased by Firm or Owner?

Yes

Current Value of Property or Lease:

DBE/ACDBE Uniform Certification Application • Page 14 of 19

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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).
Address of
Source

Name 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

DBE/ACDBE Uniform Certification Application • Page 15 of 19

Dollar Value of
Contract

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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

Additional Information:

DBE/ACDBE Uniform Certification Application • Page 16 of 19

Dollar
Value of
Contract

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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?
Type of Business
(e.g., F&B, News & Gift, Retail,
Duty Free, Advertising, etc.)

Lease
Lease
Term Start Date
(years)

Yes

No (if yes, identify the following):

Address / Location

Annual Gross
Receipts Generated

C. Does the applicant firm currently own/operate any airport concession locations?
supply the following information):
Airport Name

Concession
Number of Number of
Leases
Locations
Type
(e.g., F&B, News
& Gift, Retail,
Duty Free,
Advertising, etc.)

D. Does the applicant firm have any affiliates?
Yes
concerning any locations owned/operated by affiliate firms.

Airport Name

Annual Gross
Receipts
Generated

Yes

No (If yes,

Lease Type
(e.g., Direct Lease,
Subcontract Management
Agreement, etc. enter all that
apply to the leases listed)

No If Yes, provide the following information

Concession
Type
(e.g., F&B, News Number of Number of
Leases Locations
& Gift, Retail,
Duty Free,
Advertising, etc.)

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.

DBE/ACDBE Uniform Certification Application • Page 17 of 19

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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.

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 abovereferenced firm seeking certification as a Disadvantaged
Business Enterprise or Airport Concession Disadvantaged
Business Enterprise.
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 agree to submit to government audit, examination and I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF
review of books, records, documents and files, in whatever THE UNITED STATES OF AMERICA THAT THE FOREGOING IS TRUE
form they exist, of the named firm and its affiliates AND CORRECT. EXECUTED ON
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.
SIGNATURE
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.

(OWNER)

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

DBE/ACDBE Uniform Certification Application • Page 18 of 19

OMB APPROVAL NO: 2105-0586
EXPIRATION DATE: (05/31/2027)

U.S. Department of Transportation

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.
Business 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.
Personal Narrative. Each qualifying owner must
submit a Personal Narrative that provide evidence of
social and economic disadvantage.
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.

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.

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.

DBE/ACDBE Uniform Certification Application • Page 19 of 19