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     Firm:

    METRO SMALL BUSINESS CERTIFICATION APPLICATION

    How did you learn of Metro’s Certification Programs? (Please check one.)

     1. Metro Event? Event name:

    2. Metro Workshop? Workshop name:

    TBAC Member 3. Organization? organization:

    Metro Print 4. Describe: ad/flyer?

    5. Metro Staff? Name/Department: 6. Another Agency? Name: 7. Other? Describe:

The attached CUCP application is used by the Los Angeles County Metropolitan Transportation Authority

    (Metro) to process Disadvantaged Business Enterprise (DBE), Minority Business Enterprise (MBE), Women

    Business Enterprise (WBE) and Small Business Enterprise (SBE) certifications.

    Please check below all the certification(s) your firm is applying for:

    DBE (Submit all required documents see Document Checklist in application) Yes No

    MBE (Submit all required documents except Personal Net Worth Statement) Yes No

     WBE (Submit all required documents except Personal Net Worth Statement) Yes No

    SBE (Submit all required documents except Proof of Ethnicity/Gender) Yes No

When completed, please return, with all the supporting documents, to:

     Diversity & Economic Opportunity Department (DEOD)

     Certification Unit, Mail Stop 99-13-5

     One Gateway Plaza

     Los Angeles, CA 90012

NOTE: Failure to provide ALL required documentation will delay the processing of your certification application.

If you are pursuing a Metro contract opportunity and would like to request expedited certification, please provide

    us the following information:

    Due IFB / RFP No.: Date:

     Project Title:

Comments:

If you have any questions, please contact us at the Metro DEOD Hotline at 213-922-2600 or fax at 213-922-7660.

5/07

     U C P CALIFORNIA UNIFIED

    CERTIFICATION PROGRAM (CUCP)

     UNIFIED CERTIFICATION PROGRAM

Dear Business Owner:

Thank you for your interest in participating in the California Unified Certification Program

    (CUCP) for Disadvantaged Business Enterprises (DBEs). As mandated by the United States

    Department of Transportation (U.S. DOT) in the DBE Program, Final Rule 49 Code of Federal

    Regulations (CFR), Part 26, all U.S. DOT recipients of federal financial assistance must

    participate in a statewide UCP by March 2002. The UCP is a “One-Stop Shopping” certification

    procedure that eliminates the need for DBE firms to obtain certifications from multiple agencies

    within the State.

The CUCP is charged with the responsibility of certifying firms and compiling and maintaining

    the Database of certified DBEs for U.S. DOT grantees in California, pursuant to 49 CFR Part 26.

    The Database is intended to expand the use of DBE firms by maintaining complete and current

    information on those businesses and the products and services they can provide to all grantees of

    California.

Please complete the attached application and supplemental questionnaire if you wish to be

    considered for DBE certification and your business meets the following general guidelines:

a) The firm must be at least 51% owned by one or more socially and economically

    disadvantaged individuals.

b) The firm must be an independent business, and one or more of the socially and economically

    disadvantaged owners must control its management and daily operations.

c) Only existing for-profit “Small Business Concerns,” as defined by the Small Business Act

    and Small Business Administration (SBA) regulations may be certified. DBE applicants are

    first subject to the applicable small business size standards of the SBA. Second, the average

    annual gross receipts for the firm (including its affiliates) over the previous three fiscal years

    must not exceed U.S. DOT’s cap of $20.41 million.

    For firms applying for Airport Concession DBE certification: The Average annual gross

    receipts for the firm (including its affiliates) over the previous three fiscal years must not

    exceed $47.78 million.

d) The Personal Net Worth (PNW) of each socially and economically disadvantaged owner

    must not exceed $750,000, excluding the individual’s ownership interest in the applicant firm

    and the equity in his/her primary residence.

5/07

Page 2

Socially and economically disadvantaged individual means any individual who is a citizen of the

    United States (or lawfully admitted permanent resident) and who is a member of the following

    groups: Black American, Hispanic American, Native American, Asian-Pacific American,

    Subcontinent Asian American, or Women,

     or

    Any individual found to be socially and economically disadvantaged on a case-by-case basis by a

    certifying agency pursuant to the standards of the U.S. DOT 49 CFR Part 26.

In order to avoid unnecessary delays, please complete all portions of the application and

    supplemental questionnaire, placing "N/A" next to items that are not applicable. Include all

    copies of documents requested on the application, and have the Affidavit of Certification

    notarized. Additional documentation may be requested if it is considered necessary to make a

    certification determination. Incomplete applications/supplemental questionnaires or

    applications/supplemental questionnaires without all the required documents will not be

    evaluated until such documents are submitted. We recommend keeping a copy of all submitted

    documents for your records.

REMEMBER: It is no longer necessary to apply at more than one agency. If your firm

    meets the criteria for certification, it will be entered into the Database of DBEs for all U.S.

    DOT grantees in California. Only firms currently certified as eligible DBEs may

    participate in the DBE programs of U.S. DOT grantees of California. If you wish to be

    considered for Airport Concession DBE certification only, you will need to complete the

    Airport Concession DBE Certification Application Package, which can be accessed at

    www.dot.ca.gov/hq/bep/business_forms.htm.

The CUCP has established two Regional DBE Certification Clusters throughout the State to

    effectively facilitate statewide DBE certification activities. Please forward your completed

    certification packet to one of the agencies serving the county where your firm has its principal place of business. (See enclosed Roster of Certifying Agencies.)

    For Out-of-State Firms: The CUCP will not process a new application for DBE certification from a firm having its principal place of business in another state unless the firm has already

    been certified in that state. If your firm is located outside of California and is certified as a DBE

    at its home state, please forward your completed certification packet, along with a copy of your

    DBE certificate, to the California Department of Transportation. (See page 2 of the enclosed

    Roster of Certifying Agencies.)

     CALIFORNIA UNIFIED

     CERTIFICATION PROGRAM

5/07

INSTRUCTIONS FOR COMPLETING THE DISADVANTAGED BUSINESS ENTERPRISE (DBE)

    PROGRAM UNIFORM CERTIFICATION APPLICATION NOTE: If you require additional space for any question in this application, please attach additional sheets or copies as needed, taking care to indicate on each attached sheet/copy the section and number of this application to which it refers.

    Section 1: CERTIFICATION INFORMATION

    (4) State the date on which you and/or each other A. Prior/Other Certifications Check the appropriate box indicating for which owner took ownership of the firm. program your firm is currently certified. If you are (5) Check the appropriate box that describes the already certified as a DBE, indicate in the appropriate manner in which you and each other owner box the name of the certifying agency that has acquired ownership of your firm. If you checked previously certified your firm, and also indicate “Other,” explain in the space provided.

    whether your firm has undergone an onsite visit. If (6) Check the appropriate box that indicates whether your firm has already undergone an onsite visit/review, your firm is “for profit.”

    indicate the most recent date of that review and the NOTE: If you checked “No,” then you do NOT state UCP that conducted the review. qualify for the DBE program and therefore do not NOTE: If your firm is currently certified under the need to complete the rest of this application. The SBA's 8(a) and/or SDB programs, you may not have DBE program requires all participating firms be to complete this application. You should contact your for-profit enterprises. state UCP to find out about a streamlined application (7) Check the appropriate box that describes the legal process for firms that are already certified under the form of ownership of your firm, as indicated in 8(a) and SDB programs. your firm’s Articles of Incorporation. If you

    checked “Other,” briefly explain in the space B. Prior/Other Applications and Privileges

    Indicate whether your firm or any of the persons listed provided. has ever withdrawn an application for a DBE program (8) Check the appropriate box that indicates whether or an SBA 8(a) or SDB program, or whether any have your firm has ever existed under different ever been denied certification, decertified, debarred, ownership, a different type of ownership, or a suspended, or had bidding privileges denied or different name. If you checked “Yes,” specify restricted by any state or local agency or Federal entity. which and briefly explain the circumstances in If your answer is yes, indicate the date of such action, the space provided. identify the name of the agency, and explain fully the (9) Indicate in the spaces provided how many nature of the action in the space provided. employees your firm has, specifying the number

     of employees who work on a full-time and part-

    time basis. Section 2: GENERAL INFORMATION (10) Specify the total gross receipts of your firm for A. Contact Information

    (1) State the name and title of the person who will each of the past three years, as declared in your

    serve as your firm's primary contact under this firm’s filed tax returns.

    application. C. Relationships with Other Businesses (2) State the legal name of your firm, as indicated in (1) Check the appropriate box that indicates whether

    your firm's Articles of Incorporation or charter. your firm is co-located at any of its business (3) State the primary phone number of your firm. locations, or whether your firm shares a (4) State a secondary phone number, if any. telephone number(s), a post office box, any office (5) State your firm's fax number, if any. space, a yard, warehouse, other facilities, any (6) State your firm's or your contact person's email equipment, or any office staff with any other

    address. business, organization, or entity of any kind. If (7) State your firm's website address, if any. you answered “Yes,” then specify the name of (8) State the street address of your firm (i.e. the the other firm(s) and briefly explain the nature of

    physical location of its offices -- not a post office the shared facilities or other items in the space

    box address). provided. (9) State the mailing address of your firm, if it is (2) Check the appropriate box that indicates whether different from your firm’s street address. at present, or at any time in the past:

    (a) Your firm has been a subsidiary of any other B. Business Profile

    (1) In the box provided, briefly describe the primary firm;

    business and professional activities in which your (b) Your firm consisted of a partnership in

    firm engages. which one or more of the partners are other (2) State the Federal Tax ID number of your firm as firms;

    provided on your firm’s filed tax returns, if you (c) Your firm has owned any percentage of any

    have one. This could also be the Social Security other firm; and

    number of the owner of your firm. (d) Your firm has had any subsidiaries of its (3) State the date on which your firm was officially own.

    established, as stated in your firm’s Articles of (3) Check the appropriate box that indicates whether

    Incorporation or charter. any other firm has ever had an ownership interest

    in your firm.

    Instructions Page 1 of 3

    (4) If you answered “Yes” to any of the questions in supervisory function for any other business. If

    (2)(a)-(d) or (3), identify the name, address and you checked “Yes,” state the name of the other

    type of business for each. business and this owner’s title or function held in

    that business. D. Immediate Family Member Businesses

    Check the appropriate box that indicates whether any (7) Check the appropriate box that indicates whether of your immediate family members own or manage this owner owns or works for any other firm(s) another company. An “immediate family member” is that has any relationship with your firm. If you any person who is your father, mother, husband, wife, checked “Yes,” identify the name of the other son, daughter, brother, sister, grandmother, business and this owner’s title or function held in grandfather, grandson, granddaughter, mother-in-law, that business. Briefly describe the nature of the or father-in-law. If you answered “Yes,” provide the business relationship in the space provided. name of each relative, your relationship to them, the C. Disadvantaged Status name of the company they own or manage, the type of NOTE: You only need to complete this section for business, and whether they own or manage the each owner that is applying for DBE qualification company. (i.e. for each owner who is claiming to be “socially

     and economically disadvantaged” and whose

    Section 3: OWNERSHIP ownership interest is to be counted toward the

    Identify all individuals or holding companies with any control and 51% ownership requirements of the

    ownership interest in your firm, providing the DBE program)

    (1) Indicate in the space provided the total Personal information requested below (if your firm has more

    Net Worth (PNW) of each owner who is applying than one owner, provide completed copies of this section

    for DBE qualification. Use the PNW calculator for each additional owner): form at the end of this application to compute A. Background Information

    (1) Give the name of the owner. each owner’s PNW. (2) State his/her title or position within your firm. (2) Check the appropriate box that indicates whether (3) Give his/her home phone number. any trust has ever been created for the benefit of (4) State his/her home (street) address. this disadvantaged owner. If you answered (5) Check the appropriate box that indicates this “Yes,” briefly explain the nature, history, purpose,

    owner’s gender. and current value of the trust(s). (6) Check the appropriate box that indicates this owner’s ethnicity (check all that apply). If you Section 4: CONTROL

    checked “Other,” specify this owner’s ethnic A. Identify your firm's Officers and Board of

    group/identity not otherwise listed. Directors: (7) Check the appropriate box to indicate whether (1) In the space provided, state the name, title, date

    this owner is a U.S. citizen. of appointment, ethnicity, and gender of each (8) If this owner is not a U.S. citizen, check the officer of your firm.

    appropriate box that indicates whether this owner (2) In the space provided, state the name, title, date

    is a lawfully admitted permanent resident. If this of appointment, ethnicity, and gender of each

    owner is neither a U.S. citizen nor a lawfully individual serving on your firm’s Board of

    admitted permanent resident of the U.S., then this Directors.

    owner is NOT eligible for certification as a DBE (3) Check the appropriate box that indicates whether

    owner. This, however, does not necessarily any of your firm’s officers and/or directors listed

    disqualify your firm altogether from the DBE above perform a management or supervisory

    program if another owner is a U.S. citizen or function for any other business. If you answered

    lawfully admitted permanent resident and meets “Yes,” identify each person by name, his/her title,

    the program’s other qualifying requirements. the name of the other business in which s/he is

    involved, and his/her function performed in that B. Ownership Interest

    (1) State the number of years during which this other business.

    owner has been an owner of your firm. (4) Check the appropriate box that indicates whether (2) Indicate the dollar value of this owner’s initial any of your firm’s officers and/or directors listed

    investment to acquire an ownership interest in above own or work for any other firm(s) that has

    your firm, broken down by cash, real estate, a relationship with your firm. If you answered

    equipment, and/or other investment. “Yes,” identify the name of the firm, the officer (3) State the percentage of total ownership control of or director, and the nature of his/her business

    your firm that this owner possesses. relationship with that other firm. (4) State the familial relationship of this owner to

    each other owner of your firm.

    (5) Indicate the number, percentage of the total, class,

    date acquired, and method by which this owner

    acquired his/her shares of stock in your firm.

    (6) Check the appropriate box that indicates whether

    this owner performs a management or

    Instructions Page 2 of 3

    functions or for employee payroll. If you answered B. Identify your firm's management personnel (by

    “Yes,” briefly explain the nature of that reliance and name, title, ethnicity, and gender) who control your the extent to which the other firm carries out such firm in the following areas:

    (1) Making of financial decisions on your firm’s functions.

    behalf, including the acquisition of lines of credit, E. Financial Information

    surety bonds, supplies, etc.; (1) Banking Information (2) Estimating and bidding, including calculation of (a) State the name of your firm’s bank. (b) Give the main phone number of your firm’s cost estimates, bid preparation and submission; bank branch. (3) Negotiating and contract execution, including (c) Give the address of your firm’s bank branch. participation in any of your firm’s negotiations (2) Bonding Information and executing contracts on your firm’s behalf; (a) State your firm’s Binder Number. (4) Hiring and/or firing of management personnel, (b) State the name of your firm’s bond agent including interviewing and conducting performance and/or broker. evaluations; (c) Give your agent’s/broker’s phone number. (5) Field/Production operations supervision, including (d) Give your agent’s/broker’s address. site supervision, scheduling, project management (e) State your firm’s bonding limits (in dollars), services, etc.;(6) Office management; specifying both the Aggregate and Project (7) Marketing and sales; Limits. (8) Purchasing of major equipment; F. Identify all sources, amounts, and purposes of (9) Signing company checks (for any purpose); and money loaned to your firm, including the names of (10) Conducting any other financial transactions on persons or firms securing the loan, if other than the your firm’s behalf not otherwise listed. listed owner: (11) Check the appropriate box that indicates whether State the name and address of each source, the original any of the persons listed in (1) through (10) above dollar amount and the current balance of each loan, perform a management or supervisory function for any and the purpose for which each loan was made to your other business. If you answered “Yes,” identify each firm. person by name, his/her title, the name of the other G. List all contributions or transfers of assets to/from business in which s/he is involved, and his/her your firm and to/from any of its owners over the function performed in that other business. past two years: (12) Check the appropriate box that indicates whether Indicate in the spaces provided, the type of any of the persons listed in (1) through (10) above contribution or asset that was transferred, its current own or work for any other firm(s) that has a dollar value, the person or firm from whom it was relationship with your firm. If you answered “Yes,” transferred, the person or firm to whom it was identify the name of the firm, the name of the person, transferred, the relationship between the two persons and the nature of his/her business relationship with and/or firms, and the date of the transfer. that other firm. H. List current licenses/permits held by any owner or C. Indicate your firm's inventory in the following employee of your firm. categories: List the name of each person in your firm who holds a (1) Equipment professional license or permit, the type of permit or State the type, make and model, and current dollar license, the expiration date of the permit or license, value of each piece of equipment held and/or used by and the license/permit number and issuing State of the your firm. Indicate whether each piece is either license or permit. owned or leased by your firm. I. List the three largest contracts completed by your (2) Vehicles firm in the past three years, if any. State the type, make and model, and current dollar List the name of each owner or contractor for each value of each motor vehicle held and/or used by your contract, the name and location of the projects under firm. Indicate whether each vehicle is either owned or each contract, the type of work performed on each leased by your firm. contract, and the dollar value of each contract. (3) Office Space J. List the three largest active jobs on which your State the street address of each office space held firm is currently working. and/or used by your firm. Indicate whether your firm For each active job listed, state the name of the prime owns or leases the office space and the current dollar contractor and the project number, the location, the value of that property or its lease. type of work performed, the project start date, the (4) Storage Space anticipated completion date, and the dollar value of State the street address of each storage space held the contract. and/or used by your firm. Indicate whether your firm owns or leases the storage space and the current dollar D. AFFIDAVIT & SIGNATURE value of that property or its lease. Carefully read the attached affidavit in its entirety. Fill in D. Does your firm rely on any other firm for the required information for each blank space, and sign and management functions or employee payroll? date the affidavit in the presence of a Notary Public, who Check the appropriate box that indicates whether your must then notarize the form. firm relies on any other firm for management

    Instructions Page 3 of 3

    DISADVANTAGED BUSINESS ENTERPRISE PROGRAM

    49 C.F.R. PART 26

    UNIFORM CERTIFICATION APPLICATION

    ROADMAP FOR APPLICANTS ROADMAP FOR APPLICANTS

? Should I apply?

    o Is your firm at least 51%-owned by a socially and economically disadvantaged

    individual(s) who also controls the firm?

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

    U.S.?

    o Is your firm a small business that meets the Small Business Administration’s (SBA’s) size

    standard and does not exceed $20.41 million in gross annual receipts?

    o 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.

? 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. Under this process, the certifying agency to which you are applying will

    accept your current SBA application package in lieu of requiring you to fill out and submit this form.

    NOTE: You must still meet the requirements for the DBE program, including undergoing

    an on-site review.

    ? Be sure to attach all of the required documents listed in the Documents Check List at the end

    of this form with your completed application.

? Where can I find more information?

    o U.S. DOT http://osdbuweb.dot.gov/business/dbe/index.html

    (this site provides useful links to the rules and regulations governing the DBE program,

    questions and answers, and other pertinent information)

    o SBA http://www.ntis.gov/naics (provides a listing of NAICS codes) and

    http://www.sba.gov/size/indextableofsize.html (provides a listing of SIC codes)

    o 49 CFR Part 26 (the rules and regulations governing the DBE program)

Under Sec. 26.107 of 49 CFR Part 26, dated February 2, 1999, if at any time, the Department or a

    recipient has reason to believe that any person or firm has willfully and knowingly provided incorrect

    information or made false statements, the Department may initiate suspension or debarment proceedings

    against the person or firm under 49 CFR Part 29, take enforcement action under 49 CFR Part 31,

    Program Fraud and Civil Remedies, and/or refer the matter to the Department of Justice for criminal

    prosecution under 18 U.S.C. 1001, which prohibits false statements in Federal programs.

    Application

    Page 1 of 8

    Section 1: CERTIFICATION INFORMATION

    A. Prior/Other Certifications

    Is your firm currently certified for DBE Name of certifying agency:

    any of the following programs?

    (If Yes, check appropriate Has your firm’s state UCP conducted an on-site visit? box(es))

     Yes, on State: No

     8(a) STOP! If you checked either the 8(a) or SDB box, you may not have to

    complete this application. Ask your state UCP about the streamlined SDB application process under the SBA-DOT MOU.

    B. Prior/Other Applications and Privileges

    Has your firm (under any name) or any of its owners, Board of Directors, officers or management personnel, ever withdrawn

    an application for any of the programs listed above, or ever been denied certification, decertified, or debarred or suspended or otherwise had bidding privileges denied or restricted by any state or local agency, or Federal entity?

     Yes, on No

     If Yes, identify State and name of state, local, or Federal agency and explain the nature of the action:

    Section 2: GENERAL INFORMATION

    A. Contact Information

    (1) Contact person and Title: (2) Legal name of firm:

    (3) Phone #: (4) Other Phone #: (5) Fax #:

(6) E-mail: (7) Website (if have one):

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

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

B. Business Profile

    (1) Describe the primary activities of your firm: (2) Federal Tax ID (if any):

    (3) This firm was established on: (4) I/We have owned this firm since:

(5) Method of acquisition (check all that apply):

     Started new business Bought existing business

     Inherited business Secured concession

     Merger or consolidation Other (explain) (6) Is your firm “for profit”? STOP! If your firm is NOT for-profit, then you do NOT qualify for this ? Yes No program and do NOT need to fill out this application.

    Application

    Page 2 of 8

(7) Type of firm (check all that apply):

     Sole Proprietorship

     Partnership

     Corporation

     Limited Liability Partnership

     Limited Liability Corporation

     Joint Venture

     Other, Describe:

    (8) Has your firm ever existed under different ownership, a different type of ownership, or a different name?

     Yes No

     If Yes, explain:

(9) Number of employees: Full-time Part-time Total

    (10) Specify the gross receipts of the firm for the last 3 years:

     Year Total receipts $

     Year Total receipts $

     Year Total receipts $

    C. Relationships with Other Businesses

    (1) Is your firm co-located at any of its business locations, or does it share a telephone number, P.O. Box, office space, yard,

    warehouse, facilities, equipment, or office staff, with any other business, organization, or entity?

     Yes No

If Yes, identify: Other Firm’s name:

    Explain nature of shared facilities:

    (2) At present, or at any time in the (a) been a subsidiary of any other firm? Yes No past, has your firm: (b) consisted of a partnership in which one or more of the partners are other firms? Yes No

    (c) owned any percentage of any other firm? Yes No

    (d) had any subsidiaries? Yes No (3) Has any other firm had an ownership interest in your firm at present or at any time in the past? Yes No (4) If you answered “Yes” to any of the questions in (2)(a)-(d) and/or (3), identify the following for each:

     (attach extra sheets, if needed)

     Name Address Type of Business 1.

    2.

    3.

D. Immediate Family Member Businesses

    Do any of your immediate family members own or manage another company? Yes No If Yes, then list (attach extra sheets, if needed):

     Name Relationship Company Type of Business Own or Manager? 1.

    2.

    Application

    Page 3 of 8

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