MWBE Certification Application Form

MWBE CERTIFICATION APPLICATION FORM

WHEREAS

WHEREAS the applicant seeks certification as a Minority and/or Women-owned Business Enterprise to be recognized for participation in public and private procurement and contracting programs; and

WHEREAS the certifying authority requires the submission of factual documentation and declarations to determine ownership, control, and eligibility for MWBE status as defined by applicable statutes and regulations.

APPLICANT IDENTIFICATION

BUSINESS CHARACTERISTICS

Business Structure: Corporation LLC Partnership Sole Proprietor Nonprofit Other

CERTIFICATION REQUEST

Certification Sought: Minority-Owned Business Enterprise (MBE) Women-Owned Business Enterprise (WBE) Disadvantaged Business Enterprise (DBE)

If MBE, identify primary minority group(s): African American Hispanic / Latino Asian Native American / Alaska Native Native Hawaiian / Pacific Islander Other:

OWNERSHIP AND CONTROL

List principal owners and their ownership percentages. Attach additional sheets if necessary.

SCOPE OF WORK / SERVICES

DOCUMENTATION CHECKLIST

Check each document being submitted with this application. Additional documentation may be required to verify ownership and control.

Current business license

Articles of incorporation / organization

Operating agreement / bylaws / partnership agreement

Stock ledger / ownership records

Federal tax returns (most recent 2-3 years)

Financial statements / bank statements

Material contracts / client lists (if applicable)

Resumes of owners and key managers

Proof of identity for owners (government ID, birth certificate)

Other supporting documents — specify:

CERTIFICATION, CONSENT, AND ACKNOWLEDGMENTS

The undersigned applicant certifies, under penalty of perjury, that all information and documentation submitted with this application are true, correct and complete to the best of the applicant's knowledge. The applicant understands that false statements or material omissions are grounds for denial, suspension or revocation of certification and may subject the applicant to civil or criminal penalties.

The applicant authorizes the certifying authority to verify any information contained in this application, including but not limited to contacting banks, bonding companies, licensing agencies, and taxing authorities, and to conduct on-site visits to verify ownership, management and operations. The applicant acknowledges that certification is subject to periodic review and audit.

The applicant agrees to notify the certifying authority within thirty (30) days of any material change in ownership, management, or business structure. Certification is not transferable and applies only to the business named in this application as long as eligibility requirements continue to be met.

Confidentiality: Documents submitted will be treated in accordance with applicable law. The certifying authority may disclose information as required by law or for verification purposes; proprietary financial information will be handled with care but may be shared with contracting entities where necessary for certification determinations.

Governing Law: This application and any resulting certification determinations shall be governed by the laws of the applicable state and by the rules and regulations of the certifying authority.

Entire Agreement: This application, including attachments and supplemental documentation, constitutes the entire understanding between the applicant and the certifying authority with respect to certification and supersedes any prior communications or representations.

ATTESTATION

I hereby attest that I am authorized to execute this application on behalf of the applicant business, that the information contained herein is complete and accurate, and that I understand the obligations and penalties associated with this certification process.

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