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MWBE Certification Application Page 1 Kathy M. Sheehan Mayor City of Albany Minority & Women Owned Business Enterprise Certification Application The function of this application is to demonstrate that the business is construction-related and the applicant: owns at least 51% of the business is a woman or member of a recognized “minority” has the authority to independently direct daily business operations and enforce the policies of the business devotes time on an ongoing basis to the routine management responsibilities of the business shares in all benefits and liabilities in proportion to ownership has contributed money, equipment, property, or expertise in proportion to ownership has adequate technical expertise or managerial experience to run the business Please fill out the following form for certification in the Minority and Women Owned Business Enterprise (MWBE) Program. Complete all information and provide all requested documentation. Attach additional sheets if necessary. If a question is not applicable to your business, insert “N/A” in the space provided for your answer. The form on page 9 must be signed, dated and notarized before submitting. Additional documentation may be required. Missing documentation may result in delay or denial of certification. Name of Business Street City, State, Business Fax or Principal Federal ID This business is applying for certification as a: Minority-Owned Business Enterprise (MBE) Women-Owned Business Enterprise (WBE) Primary Business This form can also be downloaded from the MWBE page on the City of Albany website. Go to www.albanyny.gov; scroll down the home page to “Find” and click on “MWBE.” ---PAGE BREAK--- MWBE Certification Application Page 2 Is this business certified as an M/WBE by another Governmental Agency? Yes No If Yes, complete the following: (attach copies of certification letters) Date of Contact Has MWBE certification been rejected or denied by another Governmental Agency? Yes No If yes, complete the following: Date of Rejection/Denial:____________________ Contact Is this business currently involved in the bidding process or other contract/purchase order negotiations with any governmental agency, department or authority? Yes No If yes, please identify agency, department or authority. Type of Business: Corporation Date Sole Proprietorship Date Partnership Date Did the Business exist under a different type of ownership prior to the date indicated above? Yes No If yes, Explain: Has the Certification of Incorporation or business certificate been amended? Yes No If yes, Explain: Method of Acquisition (check all applicable) Started New Business Bought Existing Business Inherited Business Secured Franchise Secured Concession Merger or Consolidation Date of ---PAGE BREAK--- MWBE Certification Application Page 3 Name and Position of ALL Persons with ownership interest in the business: Name: Position: Race/Ethnic % Owned Sex Group Code (p.8) Are all owners of the business United States citizens or have legal authorization to work in the U.S.? Yes No If no, please identify individuals: List Current Board of Directors: Name: Position: Race/Ethnic Sex Group Code (p.8) Name and Title of ALL Officers of applicant business: Name: Title: Race/Ethnic Sex Group Code (p.8) Identify all individuals (Officers and/or Owners) who have an affiliation with any other business. Name Business Name/Address Telephone If applicant business is a Corporation, Identify Number of Shares: Common Common Preferred Preferred ---PAGE BREAK--- MWBE Certification Application Page 4 Gross Income of Applicant Business: Annual Payroll: Total Number of Employees___________ # Full # Part Total Number of Minorities____________ Total Number of Identify Individual(s) responsible for the following: (include sex and group code for each; see p. 8) Name Race/Ethnic Group Code Sex Financial Preparation of Purchase of Negotiating Negotiating Marketing & Negotiating Managing & Signing Payroll: Supervision of Field Operations: Signatories for Business Please identify additional staff persons. If any individual works for another business, please provide detailed information on business name, address and telephone: Office Field/Supervisory Staff: Estimator: Controller: Consultant: ---PAGE BREAK--- MWBE Certification Application Page 5 Please list all major business-related equipment owned by business: Please list all equipment rented or leased by business: (also include renter/lessor) If this business shares any space with any other business, please provide the following: Name of Business: Address: Telephone: Warehouse: Office: Storage: Garage: Attorney for business: Name: Address: Telephone: Accountant for business: Name: Address: Telephone: List three largest accounts for which the business has provided goods or services within the last two years: Business Name and Phone Location Account Amount Duration ---PAGE BREAK--- MWBE Certification Application Page 6 Identify Bank(s) where business accounts are maintained: Bank Name & Address Type of Account Account number Do you have a line of credit? Yes No If yes, identify: Source Limit Name of Guarantor(s) List major current creditors and/or lenders and types of investments and/or loans to the business: Name of Creditor/lender Type of Investment/Credit/Loan Dollar Value If your company is owned in full or in part by another business, please identify the business and the percentage of ownership interest. Business Name Address % Ownership Is your business bonded? Yes No If yes, identify: Bonding Company Telephone Primary services offered by your business. Check a maximum of FOUR options from the list below. Include documentation of licensing/certification where needed (e.g. electrical, plumbing, engineering, lead abatement) Asbestos/Lead Abatement Asphalt/Concrete Carpentry Cleaning/Janitorial Construction Services Construction: Bridge, Street, Highway Construction: General Residential/Rehab Demolition Electrical Elevator Services Engineering Environmental Estimators Excavation Fencing/Guard Rail Fire Prevention/Sprinklers Flooring/Installation Glazing HVAC Insulation Land Surveying Landscaping Masonry Painting Pavement Marking Plumbing Roofing Sealants/Caulking Signs Snow Management Steel/Iron Work Supplies/Equipment Trucking/Hauling Turf/Erosion Prevention Other Services: ---PAGE BREAK--- MWBE Certification Application Page 7 Supporting Documentation A. Required for ALL APPLICANTS. Attach copies of the following, if applicable. Please indicate documents submitted by checking appropriate boxes. Note: If appropriate documents are not submitted AND no written explanation is given, applications will be delayed or denied. Resumes of all principals, partners, officers and/or key employees of the business. Show the home address and telephone number, education, training and employment with dates. Bank signature card, bank resolution, or letter from bank identifying persons authorized to conduct transactions, level of authority and limitations, if any. Current financial statement Most recent two years Federal and State tax returns, including all schedules, where applicable. Proof of sources of capitalization/investments Proof of minority status (i.e. Birth Certificate, Baptismal Certificate, U.S. Passport etc.) Proof of United States Citizenship (i.e. Birth Certificate, Baptismal Certificate, U.S. Passport, Naturalization Certificate, etc.) OR Proof of Permanent Resident Alien status Lease agreements for office, storage and/or garage space All third party agreements including equipment rental, purchase agreements, management service agreements, etc. Any employment agreements Vehicle registration(s) Any MWBE certification, decertification or denial of certification documentation Written request for exemption from disclosure regarding trade secrets. B. Required for a Sole Proprietorship: Attach copies of the following. Please indicate documents submitted by checking appropriate boxes. Copy of Certificate of Trade Name or Business Trade Name filed with County Clerk (if doing business under an assumed name) C. Required for a Partnership and a Joint Venture Partnership: Attach copies of the following. Please indicate documents submitted by checking appropriate boxes. Business Certificate Partnership Agreement Buy Out Rights D. Required for a Corporation: Attach copies of the following. Please indicate documents submitted by checking appropriate boxes. Articles of Incorporation, including date approved by State Corporation By-Laws Minutes of First Corporate organization meeting and amendments Copies of all issued stock certificates, front and back, as well as next, un- issued certificate. Copy of stock ledger ---PAGE BREAK--- MWBE Certification Application Page 8 If applicable; furnish copies of agreements relating to: a. Stock options b. Shareholder agreements c. Shareholder voting rights d. Restrictions on the disposal of stock loan agreements e. Facts pertaining to the value of shares f. Buy out rights g. Restrictions on the control of the corporation DEFINITIONS The following definitions are consistent with both the New York State Regulations and Albany Code for Certification of Minority and Women Owned Businesses: Minority-Owned Business Enterprise (MBE) A business enterprise which is at least 51% owned by, or in the case of a publicly owned business, at least 51% of the stock is owned by citizens or permanent resident aliens meeting the ethnic definitions of Black, Hispanic, Asian, Hawaiian or Pacific Islander, Native American or Alaskan Native. Women-Owned Business Enterprise (WBE) A business enterprise which is at least 51% owned by, or in the case of a publicly owned business, at least 51% of the stock of which is owned by citizens or permanent resident aliens who are women. Group Codes: 01 Black or African American: Persons having origins in any of the Black racial groups of Africa.* 02 Hispanic/Latino: Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. 03 Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, the Pacific islands, Hawaii or Samoa.* 04 Native American or Alaskan Native: Persons having origins in any of the original peoples of North, Central and South America, who maintain cultural identification through tribal affiliation or community recognition.* 05 Two or More Races: persons who identify with two or more racial categories listed above* 06 White* * not Hispanic/Latino ---PAGE BREAK--- MWBE Certification Application Page 9 Verification State of ) ) ss: County of ) Sole Proprietorship being duly sworn, states he or she is the owner of the enterprise making the foregoing Application and that the statement and representations made in the Application are true to his or her own knowledge. Corporation/Partnership being duly sworn that he or she is the Name of Officer Officer Title Name of Corporation or Partnership Enterprise making the foregoing application, that he or she has read the Application and knows its contents; that the statements and representations made in the Application are true to his or her knowledge, and that the Application is made at the direction of the Partners, or of the Board of Directors of the Corporation. Signature Date Sworn to before me this day of Notary Public Person assisting in completing the Application: Print Full Name Signature Telephone Please return completed application to the following address: City of Albany M/WBE Office City Hall, Room 307 Albany, New York 12207 (518) 407-0255