West Virginia LLC Certificate

Disadvantaged Business Enterprise Program - Uniform Certification Application

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 $17.42 million in gross annual receipts?

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

If you answered “Yes” to all of the questions above, you may be eligible to participate in the U.S. DOT DBE program.

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

Section 1: Certification Information

A. Prior/Other Certifications

Is your firm currently certified for any of the following programs? (If Yes, check appropriate box(es))

DBE

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

8(a) SDB

B. Prior/Other Applications and Privileges

Has your firm, or any of its owners, ever withdrawn an application, been denied certification, decertified, suspended, or had bidding privileges denied or restricted?

Yes, on No

Section 2: General Information

A. Contact Information

Contact person and title:

Legal name of firm:

Phone #: Other Phone #: Fax #:

E-mail: Website:

Street address of firm (No P.O. Box): City: County/Parish: State: Zip:

Mailing address of firm (if different): City: County/Parish: State: Zip:

B. Business Profile

Describe the primary activities of your firm:

Federal Tax ID (if any):

This firm was established on I/We have owned this firm since

Method of acquisition:

Started new business Bought existing business Inherited business Secured concession

Merger or consolidation Other

Is your firm for profit? Yes No

Type of firm:

Sole Proprietorship Partnership Corporation Limited Liability Partnership

Limited Liability Corporation Joint Venture Other

Has your firm ever existed under different ownership, a different type of ownership, or a different name? Yes No

Number of employees: Full-time Part-time Total

Gross receipts for the last 3 years:

Year Total receipts $

Year Total receipts $

Year Total receipts $

Section 3: Ownership

Name: Title: Home Phone #:

Home Address: City: State: Zip:

Gender: Male Female

Ethnic group membership: Black Hispanic Native American Asian Pacific Subcontinent Asian Other

U.S. Citizen: Yes No

Lawfully Admitted Permanent Resident: Yes No

Number of years as owner:

Percentage owned:

Familial relationship to other owners:

Initial investment to acquire ownership interest:

Cash $ Real Estate $ Equipment $ Other $

Shares of stock: Number Percentage Class Date acquired Method Acquired

Does this owner perform a management or supervisory function for any other business? Yes No

If yes, Name of Business: Function/Title:

Does this owner own or work for any other firm with a relationship with this firm? Yes No

If yes, Name of Business: Function/Title:

Nature of Business Relationship:

Section 4: Control

Officers & Board of Directors

Use the fields below to enter names, titles, dates appointed, ethnicity, and gender.

Do any persons listed above perform a management or supervisory function for any other business? Yes No

If yes, Person: Title: Business: Function:

Management personnel who control the firm

Inventory

Does your firm rely on any other firm for management functions or employee payroll? Yes No

Banking Information

Name of bank: Phone No:

Address of bank: City: State: Zip:

Bonding Information

Binder No: Agent/Broker:

Phone No: Address: City: State: Zip:

Bonding limit: Aggregate limit $ Project limit $

Financial Information

Loans to firm

Transfers of assets

Signatures

Affidavit of Certification

This form must be signed and notarized for each owner upon which disadvantaged status is relied.

Executed on: Signature:

State of County of

On this of , 20 Notary Public

Commission expires: