Georgia Uniform Application

GEORGIA UNIFORM CERTIFICATION APPLICATION
DISADVANTAGED BUSINESS ENTERPRISE PROGRAM

Georgia Department of Transportation
Equal Opportunity Division
One Georgia Center, 600 West Peachtree Street, N.W., 7th Floor, Atlanta, Georgia 30308
Phone: (404) 631-1972

ROADMAP FOR APPLICANTS

Should I apply?

• Is your firm at least 51%-owned by a socially and economically disadvantaged individual(s) who also controls the firm?

• Is the disadvantaged owner a U.S. citizen or lawfully admitted permanent resident of the U.S.?

• Is your firm a small business that meets the SBA size standard and does not exceed $20.41 million in gross annual receipts?

• Is your firm organized as a for-profit business?

Is there an easier way to apply?

If you are currently certified by the SBA as an 8(a) and/or SDB firm, you may be eligible for a streamlined certification application process.

Be sure to attach all required documents listed in the Documents Checklist at the end of this form with your completed application.

Section 1: CERTIFICATION INFORMATION

A. Prior/Other Certifications

Check the appropriate box indicating for which program your firm is currently certified.

Name of certifying agency:

Has your firm's state UCP conducted an on-site visit? Yes No

Date of most recent review:

State UCP that conducted the review:

B. Prior/Other Applications and Privileges

Has your firm or any owners ever withdrawn an application, been denied certification, decertified, debarred, suspended, or had bidding privileges denied or restricted?

Yes No

If yes, date: State:

Agency and explanation:

Section 2: GENERAL INFORMATION

A. Contact Information

Contact person and title:

Legal name of firm:

Primary phone: Other phone:

Fax: Email:

Website:

Street address:

City: County/Parish: State: Zip:

Mailing address (if different):

B. Business Profile

Primary activities:

Federal Tax ID:

Established on: Owned since:

Method of acquisition:

Is your firm for profit? Yes No

Type of firm:

Ever existed under different ownership/type/name? Yes No

Employees: Full-time Part-time Total

Gross receipts for the last 3 years:

Year Total receipts $

Year Total receipts $

Year Total receipts $

C. Relationships with Other Businesses

Co-located or share facilities/equipment/staff with another business? Yes No

Other firm name:

Has your firm been a subsidiary, partnership of firms, owned another firm, or had subsidiaries? Yes No

Has any other firm had an ownership interest in your firm? Yes No

Immediate family members own or manage another company? Yes No

Section 3: OWNERSHIP

Background Information

Owner name: Title: Home phone:

Home address: City: State: Zip:

Gender: Male Female

Ethnicity:

U.S. citizen? Yes No

Lawfully admitted permanent resident? Yes No

Years as owner: Percentage owned:

Initial investment:

Family relationship to other owners:

Shares of stock / ownership details:

Management or supervisory function for any other business? Yes No

Name of business: Function/Title:

Own or work for any other firm with a relationship to this firm? Yes No

Related business name: Function/Title:

Personal Net Worth (PNW):

Trust created for benefit of this owner? Yes No

Section 4: CONTROL

Officers & Board of Directors

Any listed officers/directors perform management or supervisory function for another business? Yes No

Any listed officers/directors own or work for another related firm? Yes No

Management personnel controlling the firm

Any listed management personnel perform supervisory functions for another business? Yes No

Any listed management personnel own or work for a related firm? Yes No

Inventory, reliance, and financial information

Rely on another firm for management functions or payroll? Yes No

Banking information:

Bank name: Phone:

Bank address: City: State: Zip:

Bonding information:

Binder No: Agent/Broker: Phone:

Agent/Broker address: City: State: Zip:

Bonding limits: Aggregate $ Project $

Loan, transfer, licenses, contracts, and jobs

AFIDAVIT OF CERTIFICATION

I , swear or affirm that I am of applicant firm

Executed on

If you require additional space for any question, attach additional sheets and indicate the section and number referenced.

Sign Now