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Small Local Business Opportunity (LSBOP) Program Application Dear Prospective LSBOP Vendor: Thank you for your interest in becoming registered with Augusta, Georgia as a Local Small Business (LSB). The applicant firm must be located and operating in Richmond County for at least six months prior to submitting an application for LSB registration. “Operating” means to be the current holder of a valid business license issued by Richmond County for at least six months prior to submitting an application for LSBOP Registration. For all LSBOP registrations, the following qualifying definition shall apply: Local Small Business (LSB) means a small business concern whose average annual gross receipts or number of employees for the previous three years must not exceed: $1,500,000.00, Manufacturers – seventy-five (75) employees or less, and Wholesalers – fifty (50) employees or less. We have enclosed the LSBOP registration application. All questions on the application must be answered completely and all requested documentation must accompany the application. Failure to complete portions or provide the required documentation may result in the return of your unprocessed application and the denial of registration for your business. The information on the application must be true and accurate to the best of the applicant’s knowledge. Augusta, Georgia will keep all submitted documents and information confidential to the extent allowable by law. Registration does not guarantee any present or future contracts with Augusta, Georgia. All registered vendors must take the necessary steps to bid or propose competitively for business. Please contact our Procurement Department or visit our website to register as a vendor with Augusta, Georgia. Submit the completed application and documents to the Compliance Department, Attn: DBE/LSBOP Section, Municipal Building, 535 Telfair Street, Suite 530, Augusta, Georgia 30901. Direct all questions to the DBE/LSBOP Coordinator at (706) 821-2406 or visit our website at www.augustaga.gov for more information. Treza Edwards Compliance Director ---PAGE BREAK--- PLEASE REVIEW BEFORE COMPLETING APPLICATION MINIMUM REQUIREMENTS FOR LSBOP REGISTRATION (Please Note: This list is not exhaustive. It contains a few of the minimum, but not all, requirements for registration. Please make sure you meet the minimum requirements before completing the application for certification.) LOCATED AND OPERATING IN RICHMOND COUNTY FOR SIX MONTHS PRIOR TO SUBMITTING THE APPLICATION FOR REGISTRATION. IN POSSESSION OF A VALID BUSINESS LICENSE FROM RICHMOND COUNTY FOR AT LEAST SIX MONTHS PRIOR TO SUBMITTING THE APPLICATION FOR REGISTRATION. INDEPENDENTLY OWNED AND OPERATED BUSINESS CONCERN WHOSE AVERAGE ANNUAL GROSS RECEIPTS OR NUMBER OF EMPLOYEES FOR THE PREVIOUS THREE YEARS DOES NOT EXCEED: o GROSS RECEIPTS - $1,500,000.00 o MANUFACTURERS – 75 EMPLOYEES OR LESS o WHOLESALERS - 50 EMPLOYEES OR LESS APPLICANT FIRM MUST BE 51% OWNED BY ONE OR MORE OF THE INDIVIDUALS SUBMITTING THE APPLICATION, WHICH OWNER(S) ARE FURTHER IDENTIFIED AS “APPLICANT FIRM OWNER(S),” AND THE OWNERSHIP MUST HAVE BEEN IN EXISTENCE FOR SIX MONTHS OR MORE; THE APPLICANT FIRM OWNER(S) MUST HAVE MAINTAINED SUCH 51% OWNERSHIP FOR AT LEAST SIX MONTHS; APPLICANT FIRM OWNER(S) MUST BE A CITIZEN OR LAWFULLY ADMITTED PERMANENT RESIDENT OF THE UNITED STATES AND BE COMPLIANT WITH THE RESIDENCY REQUIREMENTS OF THE SLBE PROGRAM AS DEFINED BELOW. ---PAGE BREAK--- INSTRUCTIONS FOR COMPLETING THE LOCAL SMALL BUSINESS OPPORTUNITY PROGRAM (LSBOP) APPLICATION FORMS All questions must be answered and the requested documents submitted. The signatures of the owner(s) applying for registration must be notarized on the Registration, Citizenship and Personal Net Worth Affidavits. Failure to follow these instructions may delay the processing of the application. Questions that do not apply to your firm should be marked “N/A” in the space provided. A separate registration application should be completed for each firm applying for LSBOP registration status. SECTION I – GENERAL APPLICANT INFORMATION Provide all requested information in its entirety and be sure to include area codes for all telephone and fax numbers. If the street address and mailing address are the same please enter “Same as street address” in the area for the mailing address. If your firm is a home-based business please check “Yes”. If your company has a Federal Employer Identification Number (EIN), please provide that number. If not, please provide the Social Security number listed on the firms’ tax return. If your firm has a website please list the website address. Please provide a valid email address as this will be used as the 1st line of contact to your firm (if your email changes, remember to update your email with our office). Check the “Type of Ownership” and “Type of Business.” Check if you are locally based inside Richmond County and provide your Richmond County business license number. If you hold a State of Georgia professional license as indicated on the application, please provide a copy of the current license with your application. Provide a detailed description of the service or product your firm provides. Be as clear as possible in the description. List all NAICS codes that apply to your firm. You may refer to the NAICS (North American Industry Code Standards) code listing and provide the code(s) that best describes the service, product or work of the firm. NAICS listings can be found on the internet at SECTION II – COMPANY INFORMATION A. Complete if your firm is a Sole Proprietorship. B. Complete and provide all requested information if your firm is a Partnership. C. Complete and provide all requested information if your firm is a Corporation or a Limited Liability Company. Provide all requested information on the firm’s Officers and Board of Directors (if applicable). 1. Provide the date, city, and state where the firm was started. 2. Provide the percentage of ownership for each of the firm’s owners (list name and percentage) 3. Provide the number of employees of the firm. 4. Provide the firm’s Annual Gross Receipts for the past three years (preferably from the corporate tax return) DO NOT LEAVE BLANK. Include the year and the “Gross” receipts for that year. D. Provide the requested information for EACH owner, manager, director, or key personnel and indicate the area of control for each individual. You must provide this information even if there is only one owner, manager, director, key personnel, etc. E. Indicate if you are currently bidding on a contract with Augusta, Georgia and provide the RFB or RFP number. F. Indicate if all owners are U.S. citizens, if not you must provide proof of residency for non-citizens. SECTION III – EXPERIENCE List the three largest contracts or sales that the firm has worked on or completed in the past three years. If the firm has not worked on or completed any contracts or sales in the last three years you must provide the owner’s experience in the firm’s primary line of business including any licensures or certifications that may be applicable. ---PAGE BREAK--- Provide all requested bonding information (if applicable). REGISTRATION AFFIDAVIT Must be completed for EACH owner of the firm & must be signed and notarized. CITIZENSHIP AFFIDAVIT Must be completed for EACH owner of the firm & must be signed and notarized. PERSONAL NET WORTH STATEMENT Must be completed for EACH owner of the firm & must be signed and notarized. SUPPORTING DOCUMENTS REGISTRATION CHECKLIST – All applicants MUST follow the checklist for documentation that is required with the application. All LSBOP Registrations Applications may be mailed to or hand delivered to: Compliance Department ATTN: DBE/LSBOP Section Municipal Building, 535 Telfair Street Suite 530 Augusta, Georgia 30901 ---PAGE BREAK--- Local Small Local Business Opportunity Program (LSBOP) REGISTRATION CHECKLIST (Minimum Documents Required for All Applicants for Certification) The Local Small Local Business Opportunity Program (LSBOP) Registration Affidavit must be signed and notarized. In addition, the following supporting documentation relevant to your legal business enterprise must be submitted to the Augusta/Richmond County DBE Office. Failure to submit all required documentation may result in the return of your unprocessed affidavit and/or the denial of registration. Certification packages must be neat and legible and returned in the order listed below. The documentation required depends on the legal status of the business: Sole Proprietorship (SP); Partnership Corporation Limited Liability Company (LLC); or Limited Liability Partnership (LLP). Check the "Included" box to indicate you have provided the document or note N/A. "N/A" responses must be accompanied by a description of the item and an explanation as to why the documents were not submitted. All documents must be returned in the order listed. Failure to do so may delay the application process No. Required Documents for All Applicants SP P C LLC LLP Included 1 Resumes of owners and key management personnel showing education, training, employment and dates. X X X X X 2 Either: Picture I.D. OR Current Passport. X X X X X 3 Signed Federal Corporate Tax Returns filed by the firm and its affiliates for the past three years including all schedules and attachments. X X X X X 4 Signed Owners Personal Tax return including W-2 or 1099 form for the past three years. X X X X X 5 Completed signed and notarized Personal Net Worth Statement for EACH owner X X X X X 6 Proof of capital contribution. Indicate the manner in which ownership of the firm was obtained. Documents may include: cancelled checks, owner's first bank statement, or statement explaining how the business was started and capitalized (this must show the date the business started, etc.). X X X X X 7 Copy of lease, or a rental or management agreement for business premises, including local business phone number, a copy of your deed if the premises are owned, or a notarized statement that the business is home based. X X X X X 8 A list of equipment owned or available (include description of equipment, year acquired, and current value) and copies of lease or purchase agreement (if applicable) X X X X X 9 Vehicle registration for all company owned vehicles (if applicable). X X X X X 10 Copies of all certification and denial of certification letters (if applicable). X X X X X 11 Copy of current year’s business license which shows the company is located in Richmond County (applicant must possess a valid Augusta, Georgia business license for 6 months prior to submitting the LSBOP registration application). X X X X X 12 Applicable contractors, professional license(s) and/or permit(s). X X X X X 13 Two executed (i.e. signed by all parties) copies of past/ current contracts/ proposals or purchase order/invoice in full. This information must include name/ address/ contact person of other company, type of work performed or type of contract received and date work completed. One copy must document work for the current year and the second copy must document the previous year's work. Submitted proposals and/or estimates can be provided in lieu of executed contracts IF the firm has not performed work previously. X X X X X 14 Proof of bonding capacity (if applicable). X X X X X 15 Bank signature card (showing date account opened and title of all signers, ex: Pres., etc.). X X X X X Corporation SP P C LLC LLP Included 16 Official Articles of Incorporation from the Secretary of State X 17 Copies of all stock certificates issued to date (include front & back sides of any canceled or replaced certificates) do not include specimen copies and your firm’s stock transfer ledger. X 18 Shareholders ‘Agreements or any agreements related to Stock options, Stockholder voting rights, Ownership agreements, Ownership of voting securities, Stockholder agreements, Facts pertaining to the value of shares, Restrictions on the disposal stock loan agreements. X 19 Minutes of the following meetings: Organizational meetings; Shareholder meetings for the past 24 months; Board of Directors meetings for the past 24 months. X 20 Corporate By-Laws. X ---PAGE BREAK--- Limited Liability Corporation (LLC) 21 Official Articles or Certificate of Organization from the Secretary of State X 22 Copies of all stock certificates issued to date (include front & back sides of any canceled or replaced certificates) do not include specimen copies and your firm’s stock transfer ledger. (If applicable) X X 23 Partnership Agreement, including the following major causes Buy-out rights, Profit sharing plan, Capital contribution agreement. X X 24 Minutes of the following meetings: Organizational meetings; Shareholder meetings for the past 24 months; Board of Directors meetings for the past 24 months (if applicable). X 25 Official Operating Agreement X Limited Liability Partnership or Joint Ventures 26 Original and any amended Partnership or Joint Venture Agreements X X ---PAGE BREAK--- LOCAL SMALL BUSINESS OPPORTUNITY PROGRAM AUGUSTA, GEORGIA COMPLIANCE DEPARTMENT 535 TELFAIR STREET, SUITE 530 AUGUSTA, GEORGIA 30901 Phone: (706) 821-2406 Email: [EMAIL REDACTED] Web Site: www.augustaga.gov LOCAL SMALL BUSINESS OPPORTUNITY PROGRAM REGISTRATION APPLICATION Revised: 08/09/19 (THIS IS NOT A DBE PROGRAM) SECTION I – GENERAL APPLICANT INFORMATION Firm Name Firm’s Federal EIN Number Name of Owner Title Contact Person Title Street Address of Business City County State Zip Is this a home based business Yes No Mailing Address (if different from street address) City County State Zip Telephone Number Fax Number Web Site Email Address TYPE OF OWNERSHIP: APPLYING FOR LOCAL SMALL BUSINESS: Sole Proprietor Locally based inside Richmond County Partnership Business License Limited Liability Partnership PROFESSIONAL LICENSURES Electrician Utilities Contractor General Contractor Corporation Limited Liability Company Please provide a copy of your State of GA license. Joint Venture TYPE OF BUSINESS: Construction Professional Services / Non-Engineering or Architectural Professional Services - Engineering Professional Services - Architectural Goods & Services – Manufacturer Goods & Services / Non-Manufacturer ---PAGE BREAK--- Description of firm’s primary line of business: (Include all scopes of services/products. This is how your business will be categorized and listed on our certified vendor report.) List all NAICS codes that apply to your firm: (visit to search for your code) SECTION II – COMPANY INFORMATION: Please complete the section below that applies to your business. A. SOLE PROPRIETORSHIP Does the owner report as his/her personal income, for State and Federal income tax purposes, the funds from such business? Yes No B. PARTNERSHIP Is fifty-one percent (51%) of the Applicant Firm owned by one or more of the Applicant Firm Owner(s) identified? Yes No Do the owners report as their personal income for State and Federal income tax purposes more than fifty percent (50%) of the income of the partnership? Yes No Name(s) of Partners: Name Title Race / Ethnicity Period of Service mm/yy From To Percentage of Ownership Date (month, day, year) organized as a partnership in state of Date (month, day, year) of initial operation in state of C. CORPORATION and/or LIMITED LIABILITY COMPANY/PARTNERSHIP Is this business organized as a corporation in which a majority of the stock is owned by the Applicant Firm Owner(s)? Yes No If the above answer is yes, does the owner report his/her personal income for State and Federal income tax purposed more than fifty percent (50%) of the distributed earnings of the corporation? Yes No Date (mm/dd/yyyy) Incorporated in state of Total commons shares issued as of date of this application: Common: Preferred: Other: ---PAGE BREAK--- OFFICERS AND BOARD OF DIRECTORS Enter ALL corporate Officers, Directors, and Shareholders – including Officers and Directors who do not own stock in the business. List all titles for individuals/entities holding multiple titles Name Title Race / Ethnicity Period of Service mm/yy From To Percentage of Ownership Note: The Local Small Business Opportunity Program is a race and gender-neutral program. The disclosure of race/ethnicity and gender is voluntary. Date business started and location: Percent of ownership held by Applicant Firm Owner(s): Number of Firm’s Annual Gross Receipts for previous three years: (DO NOT LEAVE BLANK) Year Annual Gross Receipts D. CONTROL Name *Race/ Ethnicity *Gender M/F Title Financial Decisions Management Decisions Marketing Decisions Mgt. Technical Personnel Field Supervisor E. Are you currently bidding on a contract for Augusta, Georgia? Yes No If yes, indicate name of RFB, RFP or invitation number. F. Are all owners U.S. Citizens: Yes No If “no”, submit proof of residency for non-citizens. ---PAGE BREAK--- SECTION III – EXPERIENCE List three largest projects (in the past three years) the firm has worked on or completed. Include project owner, type of work performed, and contact Person’s name, address and telephone number, and dollar amount of project. If the firm has not worked on or completed any projects list the owner’s experience in the firm’s primary line of business. A. Project owner: Type of work Performed: Contact person’s name, address, and telephone number: Amount of project: Date completed: Owner’s experience if no prior worked on or completed projects: B. Project owner: Type of work Performed: Contact person’s name, address, and telephone number: Amount of project: Date completed: Owner’s experience if no prior worked on or completed projects: C. Project owner: Type of work Performed: Contact person’s name, address, and telephone number: Amount of project: Date completed: Owner’s experience if no prior worked on or completed projects: D. Bonding Information: If you have bonding capacity identify the following: Name of Agent/Broker: Bonding Limit: Aggregate Limit: Project Limit: ---PAGE BREAK--- REGISTRATION AFFIDAVIT This form must be signed and notarized for EACH owner. A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS SUFFICIENT CAUSE FOR DENIAL OF REGISTRATION, REVOCATION OF A PRIOR APPROVAL, INITIATION OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY MAKING THE FALSE STATEMENT TO CIVIL AND CRIMINAL PENALTIES AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW. I name printed), swear or affirm under penalty of law that I am of (firm name) and that I have read and understood all of the questions in this application and that all of the foregoing information and statements submitted in this application and its attachment and supporting documents are true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information. 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 application is for the purpose of inducing registration approval by Augusta-Richmond County. I understand that Augusta-Richmond County may, by means it deems appropriate, determine the accuracy and truth of the statements in the application, and I authorize the DBE Department to contact any entity named in the application, 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. I further certify name) three year average annual gross receipts do not exceed $1.5 million, my principal office is located in Augusta-Richmond County and the business owner(s) personal net worth is less than $750,000. I declare, under penalty of perjury, that the information provided in this application and supporting documents relating to my business status and me is true and correct. Signature: Date: NOTARY CERTIFICATE: State of Georgia County of Sworn to (or affirmed) and subscribed before me this day of by (Name of person making statement) Seal: (Signature of Notary Public-State of Georgia) Pint, Type, or Stamp Commissioned Name of Notary Public) Personally known OR Produced Identification. Type of Identification______________ COMPLETION OF THIS FORM IS MANDATORY. ---PAGE BREAK--- CITIZENSHIP O.C.G.A. § 50-36-1(e) Affidavit By executing this affidavit under oath, as an applicant for a LSBOP Registration, as referenced in O.C.G.A. § 50-36-1, from Augusta, Georgia, I, the undersigned applicant, verify one of the following with respect to my application for a public benefit: 1) I am a United States citizen. 2) I am a legal permanent resident of the United States. 3) I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency. My alien number issued by the Department of Homeland Security or other federal immigration agency is: I, the undersigned applicant, also hereby verifies that I am 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e) with this affidavit. The secure and verifiable document provided with this affidavit can best be classified as: In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute. Executed in (city), (state). Signature of Applicant Date Sworn to and subscribed before me Seal: This day of , 20 Notary Public My Commission Expires: COMPLETION OF THIS FORM IS MANDATORY. ---PAGE BREAK--- LOCAL SMALL BUSINESS OPPORTUNITY PROGRAM DISADVANTAGED BUSINESS ENTERPRISE Augusta-Richmond County 535 Telfair Street, Suite 530 Augusta, Georgia 30901 Personal Net Worth Statement As of 20___ (These statements are not subject to public disclosure) Complete this for: each proprietor, or each limited partner or general partner, or each stockholder. Name: Business Phone: Residence Address: Residence Phone: City, State and Zip Code: Business Name of Applicant: ASSETS (Omit Cents) LIABILITIES (Omit Cents) Cash on hand & in Banks Savings Account IRA or Other Retirement Account Accounts & Notes Receivable Life Insurance – Cash Surrender Value Only Stocks and Bonds Real Estate Automobile-Present Value Other Personal Property Ownership in Other Business Total Assets $ $ $ $ $ $ $ $ $ $ $ Accounts Payable Notes Payable to Banks and Others Installment Account (Auto) Payments Installment Account (Other) Payments Loan on Life Insurance Mortgages on Real Estate Unpaid Taxes Other Liabilities Total Liabilities $ $ $ $ $ $ $ $ $ $ $ Net Worth (Total Assets Minus Total Liabilities) $ I hereby certify that no assets have been transferred to any beneficiary for less than fair market value in the last two years. I authorize the Augusta-Richmond County Disadvantaged Business Enterprise Department to verify the accuracy of the statements made in order to determine whether I meet the standards for participation in the Local Small Business Opportunity Program. These statements are true and correct to the best of my belief. Signature Date Social Security Number ---PAGE BREAK--- PERSONAL NET WORTH AFFIDAVIT Local Small Business Opportunity Program (LSBOP) (These statements are not subject to public disclosure)1 Firm name: Please provide net worth information for each owner by completing the appropriate sections as requested below in order for this department to determine whether your firm is eligible for participation in the Local Small Business Opportunity Program (LSBOP). Personal Net Worth means the sum of the fair market value of the interests owned by an individual in all assets, minus the debt of the individual. If an asset is owned jointly as husband and wife, then fifty percent (50%) of the fair market value for that asset will be counted if only one spouse participates in the firm being reviewed. If debt is attributable to an asset owned jointly as husband and wife, then fifty percent (50%) of the debt will be counted if only one spouse participates in the firm being reviewed. Up to $750,000 of the equity or debt in the individual’s Primary Residence may be excluded when determining the Personal Net Worth as well as the individual’s ownership in the applicant firm. Section 1 Section 2 Section 3 Owner’s Name Ownership % Personal Net Worth AFFIDAVIT I swear that the foregoing statements are true and correct and include all the information necessary to determine the Personal Net Worth (PNW) of the firm’s owner(s). Further, I understand that the Disadvantaged Business Enterprise Department reserves the right to conduct investigations and request additional information necessary to verify the statements and information provided. Sworn to and subscribed before me this of Executed by: (Name of Firm) Signature of Owner: Notary Public: Printed Name of Owner: My Commission expires on: Title: 1The information submitted in this application is for the purpose of inducing registration approval by Augusta-Richmond County’s Local Small Business Opportunity Program. To the maximum extent permitted by the Georgia Open Records Act and other applicable law, Augusta-Richmond County seeks to protect the financial records of a business, including balance sheets and financial statements. ---PAGE BREAK---