MUSKEGON COUNTY UNIFIED CERTIFICATION APPLICATION FOR DISADVANTAGED, MINORITY AND WOMEN-OWNED BUSINESS ENTERPRISES

Transcription

1 MUSKEGON COUNTY UNIFIED CERTIFICATION APPLICATION FOR DISADVANTAGED, MINORITY AND WOMEN-OWNED BUSINESS ENTERPRISES APPLICATION FEE $25 May 2003 Last revised 2/25/04 MAY 2003

2 MUSKEGON COUNTY UNIFIED CERTIFICATION PROGRAM Introduction Inclusion of minority, women and/or socially and economically disadvantaged-owned businesses in the economic mainstream of America is a national imperative. As our nation becomes more and more diverse and recognizes the cultural and social constructs, which perhaps are more natural than one would care to acknowledge, it becomes a growth and development necessity to diversify the economic capacity of the citizenry. Leading national companies such as GM, FORD, CHRYSLER, etc. have discovered that to remain competitive and leaders in their fields one must decisively diversify its supplier base. GENERAL OVERVIEW The Unified Certification Program is a county-wide effort focused on providing measurable exposure for minority, women and/or socially and economically disadvantaged-owned businesses. The names and certification status of all known minority, women and/or socially and economically disadvantaged-owned businesses shall appear in our local DBE and business directories. These directories will be disseminated to all local government agencies, contractors and the general public. Agencies, contractors, etc. will be encouraged to use the directories as a basic resource for soliciting minority, women and/or socially and economically-owned disadvantaged businesses for participation in its projects and programs. Certification applicants are required to complete the Muskegon County Purchasing Vendor registration via the internet at Certification provides a mechanism for an agency, contractor, etc. to measure the effect and outcomes of its good-faith efforts toward inclusion. The Unified Certification Program is meant only to authenticate the ownership and management of the business enterprise. Assessing a business enterprise s qualifications and capabilities remains the responsibility of the respective agency, contractor, etc. Certification determinations are processed by a certification review committee of the Supplier Diversity Conference Advisory Board which will meet quarterly. Certification may take anywhere from three (3) to six (6) months from the date of receipt of a completed application. An application fee of twenty-five ($25) dollars is required w/application. All information will be processed in the strictest of confidence. The information sought is self-explanatory and typical of the kinds of things one would think about as they structure their business operations. We do not anticipate that one would need to hire external assistance in completing the application. In the event that clarification is needed on any questions in the application packet, you may contact the Muskegon County EEO office at (231) for assistance. Certification is good for three years. Those firms, who already possess a certification from another agency, need only to complete and submit pages 4 13, send in the application fee and complete a vendor registration from the Purchasing Office. The firm need not complete or submit any other portions of the certification. Certifications that will be accepted by Muskegon County are MMBDC, MUCP, and NAWBO. DEFINITIONS Certified means that the minority, woman or socially and economically-owned business has been authenticated as being at least 51% owned and controlled either by minorities, females or socially and economically disadvantaged individuals for participation in programs requiring certification as determined by the Unified Certification program participants. Disadvantaged Business Enterprise (DBE) means small business: a) which is at least 51% owned by one or more socially and economically disadvantaged individuals, or in the case of any publicly owned business, at least 51% of the stock which is owned by one or more socially and economically disadvantaged individuals; and b) whose management and daily business operations are controlled by one or more of the socially and economically disadvantaged individuals who own it. Minority means a person who is: 1) Black, which is a person having origins in any of the black racial groups in Africa; or 2) Hispanic, which is a person of Spanish or Portugese culture, with origins in Mexico, South or Central America, or the Carribbean Islands, regardless of race; or 3) Asian American, which is a person having origins in any of the original peoples of the Far East, Southeast Asia, India Subcontinent, Hawaii, or the Pacific Islands; or 2

3 4) Native American (American Indian or Alaskan native), which is a person having origins in any of the original peoples of North America Minority Business Enterprise (MBE) means a business that is: a) A sole proprietorship, partnership or joint venture owned and controlled by minorities in which at least 51% of the ownership interest is held by minorities and the management and daily business operations are controlled by one or more of the minorities who own it; or b) A corporation or other business entity authorized under the laws of the United States whose management and daily business operations is controlled by one or more minorities who own it and which is at least 51% owned by one or more minorities or, if stock is issued, at least 51% of the stock is owned by one or more minorities. Women Business Enterprise (WBE) means a business that is: a) A sole proprietorship owned and controlled by a woman; b) A partnership or joint venture owned and controlled by women in which at least 51% of the ownership is held by women and the management and daily business operations of which are controlled by one or more women who own it; or c) A corporation and other business entity authorized under the laws of the United States whose management and daily business operations are controlled by one or more women who own it and which is at least 51% owned by women or, if stock is issued, at least 51% of the stock is owned by one or more women. CERTIFICATION STANDARDS and APPEALS A firm seeking certification has the burden of demonstrating, by a preponderance of the evidence, that it meets the requirements concerning group membership or individual disadvantage, business size, ownership, and control. 1. Certification Denials - If a firm is denied certification, it will receive a written explanation of the reasons for the denial, specifically referencing the evidence in the record that supports each reason for the denial. All documents and other information on which the denial is based will be made available to the applicant, on request. Firms that have been denied may not reapply until after six (6) months has elapsed. 2. Certification Removal If a written complaint alleging ineligibility of a currently certified firm specifying the alleged reasons why it s ineligible is received, a review will be conducted. If during this review there is reasonable cause to believe that the firm is ineligible, a written notice will be sent to the firm, setting forth the reasons for the proposed ineligibility determination. If during the review there is not reasonable cause to believe that the firm is ineligible, a written notice will be sent to the complainant and the firm, setting forth the reasons for such finding. 3. Certification Appeals If a firm wishes to file an appeal of any determination made by the certification review committee, it must send a letter to the Muskegon County Equal Opportunity Office within 90 days of the date of the final decision, including information and arguments concerning why the decision should be reversed. The Equal Opportunity Office will have 60 days to conduct a review and either affirm or repeal the denial. The Equal Opportunity Office s determination is final. A written letter of determination will be sent to the firm acknowledging the finding. 3

4 MUSKEGON COUNTY DBE/MBE/WBE CERTIFICATION INITIATIVE UNIFORM CERTIFICATION APPLICATION General Instructions: (PLEASE TYPE OR PRINT CLEARLY. DO NOT LEAVE ANY SPACES BLANK ON THE APPLICATION.) If a question is not applicable to your business insert N/A in the space provided for your answer. You may make photocopies of the completed application as necessary. Whenever the space is insufficient to answer the questions completely, attach additional sheets as necessary. Use the question number to identify any answer continued on an additional sheet. 1a. Name and Street Address of Applicant Firm (Enter the full legal name of the enterprise. For example, a corporation named ABC Construction, Inc. should be identified as ABC Construction, Inc., not as ABC Construction ). 1b. Doing Business As (D/B/A) Name (Complete if firm does business under an assumed or trade name that is different from its legal name.) 1c. Mailing Address (Complete if different from street address.) 2. Business Phone Number: ( ) FAX: ( ) 3. Federal Employer Identification Number OR Social Security Number (A Federal Employer Identification Number is required for most business activities. For an application and/or additional information, contact the U.S. Internal Revenue Service at (800) Sole proprietorships may submit social security number of the owner in lieu of the federal identification number.) 4a. Name of Company President/Chief Executive Officer/Owner President Chief Executive Officer Owner 4b. Name & title of officer of the firm who can be contacted during the application review process. Name Title 5. This Firm is applying for certification as: (Please refer to page 12 of this application to determine the appropriate designation for your company. One or more categories may be designated.) 9 Minority Business Enterprise (MBE) 9 Disadvantaged Business Enterprise (DBE) 9 Women-Owned Business Enterprise (WBE) 4

5 6. Does this firm have current Small Business Administration (SBA) 8(a) status? 9 Yes 9 No If Yes, please attach a copy of the SBA letter of approval. 7. Are you currently involved in the bidding process or other contract/purchase order negotiations with any governmental agency, department or authority? 9 Yes 9 No If Yes, please identify agency, department or authority. 8a. Type or ownership (Please specify current ownership.) 9 Sole Proprietorship Certificate of Trade Name on file in 9 Partnership Business Certificate for Partners on file in 9 Corporation Certificate of Incorporation on file in 8b. Did the business exist under a different type of ownership prior to the date indicated in question 8a? 9 Yes 9 No If Yes, Explain 8c. Has your Certificate of Incorporation or business certificate been amended? 9 Yes 9 No If Yes, Explain 8d. Method of Acquisition (check all applicable): 9 Started New Business 9 Secured Franchise 9 Other 9 Bought Existing Business 9 Secured Concession 9 Inherited Business 9 Merger or Consolidation Date of Acquisition 8e. Name & Position of all person(s) with ownership interest. Check all that are applicable. (If no positions are held, state none.) US Citizen or Group Permanent Name Position Code* %Owned Sex Resident Alien 9 Male 9 Female 9 Yes 9 No 9 Male 9 Female 9 Yes 9 No 9 Male 9 Female 9 Yes 9 No *Group Code Key (Please refer to Page 16 for Definitions.) 01 - Black 02a - Hispanic 03a - Asian-Pacific 04 - Native American 02b - Portuguese 03b - Asian-Indian 05 Resident of Public Housing 02c Spanish 05a Low Income persons living in areas where a HUD-assisted project is located 5

6 9. Please identify the cash and capital contributions to the firm by those identified in 8e, including gifts, equipment, loans and expertise. Contributor Amount/Value Type/Date of Contribution 10a. If the firm is a partnership, please complete for all partners. Total Amount/Value Date of Name of Contributions Ownership 10b. If the firm is a corporation, please complete for all shareholders. Common Amount No of or Paid When Date of Name Share Preferred Purchased Ownership 10c. If a corporation, number of shares: Common Authorized Preferred Authorized Common Issued Preferred Issued 11. Gross Receipts (Sales). Please provide gross receipts for the last 3 years. (If in business less than 3 years complete as applicable.) $ $ $ Current Year (20 ) Last Year (20 ) Previous Year (20 ) 6

7 12. Number of employees (Please average over the past year.) Permanent Full-Time Part-Time Temporary Full-Time Part-Time 13. If licensing, permits or accreditation is required to conduct the business, please identify: Type or License/Permit Issued by Issue Date Exp. Date Holder/Registrant 14a. Check all that best describe the business operation. 9 Construction-Related 9 Consumer Service 9 Professional Service 9 Manufacturer/Supplier 9 Technical Service 9 Retail 9 Other (explain) 14b. Describe principal products/commodities sold, specialties or services offered (Please explain) 15a. Identify those individuals responsible for managerial operations (State if owner or non-owner.) *For Group Codes, see Page 16. Group Name & Title Sex Code* Owner or Non-Owner 1. Financial Decisions 2. Estimating 3. Preparing Bids 7

8 Group Name & Title Sex Code* Owner or Non-Owner 4. Negotiating Bonding 5. Negotiating Insurance 6. Marketing & Sales 7. Hiring & Firing 8. Supervising Field Operations 9. Purchasing Equipment/Supplies 10. Managing & Signing Payroll 11. Negotiating Contracts 12. Signators for Business Accounts 8

9 15b. Please identify additional staff persons. If any individual also works for another firm, please check yes and provide the person s name, his/her position, other firm s name, address and telephone number. 1. Office staff Name & Position Other Firm Name, Address Phone 9 Yes 9 No ( ) 9 Yes 9 No ( ) 2. Field/supervisory staff 9 Yes 9 No ( ) 9 Yes 9 No ( ) 3. Estimator 9 Yes 9 No ( ) 9 Yes 9 No ( ) 4. Controller 9 Yes 9 No ( ) 9 Yes 9 No ( ) 5. Consultant (for firms involved in providing consultant/technical service or advisory services) 9 Yes 9 No ( ) 9 Yes 9 No ( ) 15c. If this firm shares the following with any other firm, please provide the other firm s name, address & telephone number. 1. Office Space Other Firm Name Address Phone _ ( ) ( ) 2. Yard space _ ( ) ( ) 3. Equipment (include rentals) _ ( ) ( ) 9

10 16a. List rented, leased, or owned warehouse, plant, yard, and office facilities. Owner or name of If rented or leased, Facility type Lessor and/or rental agent Amount of yearly rent payments 16b. List major equipment or machinery that is owned or leased by the firm. Depreciated Acquisition Payment Type dollar value date terms 17. Do any principals, officers and/or owners of the firm have an affiliation (i.e. business interest or employment) with any other firm? 9 Yes 9 No If Yes, please complete the following: Name of Firm name Phone Nature of Nature of Person & address number business affiliation ( ) ( ) ( ) ( ) ( ) 18. Attorney for firm Name: Street Address: City: State: Zip Code: Phone Number: ( ) 10

11 19. C.P.A. or Accountant for firm Name: Street Address: City: State: Zip Code: Phone Number: ( ) 20a. Has the firm applied for certification as an M/WBE, or DBE with another governmental agency, department or authority? 9 Yes 9 No If Yes, complete the following: Specify Agency Date Contact Person Phone M/W/DBE 1. Pending with 2. Certified by 3. Registered by 4. Withdrawn/Closed Out 5. Rejected by 6. Denied by 7. Decertified by 20b. Are there appeals pending on any of the above applications or certifications? 9 Yes 9 No Agency Date of Appeal Contact Person Phone ( ) ( ) ( ) ( ) 11

12 21. List the three largest accounts for which the applicant has provided goods or services within the last two years: Account Dollar Location of Firm Name & Phone Amount Performance Duration 22. Identify Bank(s) where firm s accounts are maintained. Bank Name Address Contact Type of Account Account No. 23. Do you have a line of Credit? 9 Yes 9 No If Yes, Identify Source Limit Name of Guarantor(s) 24. List major current creditors and/or lenders and types of investment and/or loans in the firm. Name of Type of investment/ Dollar value of investment/ creditor/lender credit/loan terms/credit/loan 25. If your company is owned in full or in part by another firm, please identify the firm and the percentage of ownership interest. Include venture capitalists and other similar investors. Firm Name Address Percentage Ownership 12

13 Is the firm bonded? If yes, specify type and limit. 9 Yes 9 No Bonding Company Type Limit Address Telephone ( ) Contact Person 13

14 SUPPORTING DOCUMENTS 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, application will be returned to you. 1. Resumes of all principals, partners, officers and/or key employees of the firm as per 8(e), 10(a) and 15(a). Show home address and telephone number, education, training and employment with dates. 2. Bank signature card, bank resolution, or letter from the bank identifying persons authorized to conduct transactions, level or authority and limitations, if any. 3. Current financial statement. 4. Most recent three years Federal (corporate and personal) tax returns including all schedules, where applicable. 5. Proof of sources of capitalization/investments. 6. Proof of ethnicity (i.e., Birth Certificate, Baptismal Certificate, U.S. Passport, etc.) 7. Proof of U.S. Citizenship (i.e., Birth Certificate, Baptismal Certificate, U.S. Passport, Naturalization Certificate, etc.) 8. Proof of permanent resident alien status, i.e., permanent resident ( green ) card. 9. Lease Agreements per 16(a) and 16(b) for business premises. 10. All third party agreements including: equipment rental, purchase agreements, management service agreements, etc. 11. Any employment agreements 12. Vehicle registration(s). 13. Any certification, decertification or denial of certification documentation. 14. Proof of Small Business Administration 8(a) Certification (copy of all approval letters). 15. 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.) 1. 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.) 1. Business Certificate 2. Partnership agreement 3. Buy-out Rights 14

15 D. REQUIRED FOR A CORPORATION (Attach copies of the following: Please indicate documents submitted by checking appropriate boxes.) 1. Articles of incorporation, including date approved by State 2. Corporation By-Laws 3. Minutes of first corporate organizational meeting and amendments. 4. Copies of all issued stock certificates, front and back, as well as next, unissued certificate. 5. Copy of stock ledger. 6. If applicable, furnish copies of agreements relating to; o stock options o shareholder agreements o shareholder voting rights o restriction on the disposal of stock loan agreements o facts pertaining to the value of shares o buy-out rights o restrictions on the control of the corporation 7. List of current Board of Directors including group code, sex and effective dates. Group Name Position Code Sex Date 9 Male 9 Female 9 Male 9 Female 9 Male 9 Female 9 Male 9 Female 9 Male 9 Female 9 Male 9 Female 15

16 DEFINITIONS OF MBE, WBE AND DBE (To be used to answer Question 5, Page 1) MINORITY BUSINESS ENTERPRISE (MBE) - A business enterprise which is at least fifty-one percent (51%) owned by, or in the case of a publicly owned business at least fifty-one percent (51%) of the stock of which is owned by citizens or permanent resident aliens meeting the ethnic definition of: 01 Black 02a Hispanic 03a Asian-Pacific 03b Asian-Indian 04 Native American WOMEN-OWNED BUSINESS ENTERPRISE (WBE) - A business enterprise which is at least fifty-one percent (51%) owned by, or in the case of a publicly owned business at least fifty-one percent (51%) of the stock of which is owned by citizens or permanent resident aliens who are women. DISADVANTAGED BUSINESS ENTERPRISE (DBE) - a small business concern which is at least fifty-one percent (51%) owned and controlled by one or more socially and economically disadvantaged individuals or, in the case of a publicly owned business at least fifty-one percent (51%) of the stock of which is owned by one or more socially and economically disadvantaged individuals; and whose management and daily business operations is controlled by one or more such individuals. Socially and economically disadvantaged individuals are individuals who are citizens or lawful permanent residents of the United States and are: 01 Black 02a Hispanic 02b Portuguese 02c Spanish 03a Asian-Pacific 03b Asian-Indian 04 Native American 05 Residents of Public Housing 05a Low Income persons living in areas where a HUD-assisted project is located Women, regardless of race or ethnicity Members of other groups or other individuals found, on a case-by-case basis, to be economically and socially disadvantaged by the U.S. Department of Transportation grant recipients or the Small Business Administration under Section 8(a) of the Small Business Act, as amended (a5 U.S.C. 637) UNDER EACH CERTIFICATION CATEGORY, OWNERSHIP MUST BE REAL, SUBSTANTIAL AND CONTINUING. THE APPLICANT MUST HAVE AND EXERCISE THE AUTHORITY TO INDEPENDENTLY CONTROL THE BUSINESS DECISIONS OF THE ENTERPRISE. 16

17 FRAUD The undersigned does hereby swear that the statements contained in this application and all attachments that have been provided in support of this application (hereafter referred to as this application ) are true, accurate, and complete and include all material information necessary to identify and explain the ownership and operation of: (Insert Full Name of Applicant Company Here) Further, the undersigned does covenant and agree to provide the Muskegon County Unified DBE Opportunity Advisory Committee (hereafter referred to as the DBOC ) with current, complete, and accurate information regarding this application, its attachments, or any project or contract issued by its corporate members. The undersigned further agrees that, as part of this certification procedure, DBOC may freely contact any person or organization named in this application to verify statements made in this application and/or to secure additional information or data required to grant to, or withhold from, the applicant company certification as a Minority Business Enterprise, a Women business Enterprise (or both) or a Disadvantaged Business Enterprise. The undersigned understands and agrees that failure to submit required materials and/or to consent to interview(s), audit(s), and/or examination(s) will be grounds for immediate rejection of this application for certification or recertification. It is recognized and acknowledged that the statements contained in this application have been given under oath and that any material misrepresentation will be grounds for denial or certification or for decertification and may result in not awarding or terminating contracts which may be awarded as the result of information contained in this application. The undersigned further acknowledges that information contained in this application may be shared with any public department, agency, etc., which is responsible for providing funding used to fulfill contracts arising from the representations made in this application. The release of such information will be subject to all laws of the State and Federal government applicable to the treatment of confidential information and/or material. It is further understood that certification as an MBE, WBE, M/WBE, or DBE will be suspended for a period of up to, but not exceeding, two years if, after proper investigation by DBOC, the applicant is determined to be engaging in activities which circumvent the intent of the Muskegon County Unified DBE Program. The applicant further understands that misrepresentations made in this application are subject to all laws of the State of Michigan which deal with civil and criminal fraud. Under these laws convictions may result in fines up to $100,000 (or any higher amount equal to double the pecuniary gain to the offender or lost to the victim) or a jail term of between five and ten years. The undersigned further acknowledges that certification is normally reviewed annually but that DBOC retains the right to reevaluate the contents of this application at any time. I have read and acknowledge the foregoing. Signature of Applicant Corporate Seal (if applicable) 17

18 VERIFICATION (A) (B), being duly sworn, states he or she is the owner of (or a partner Name of Applicant in) the enterprise making the foregoing Application and that the statements and representations made in the Application are true to his or her own knowledge., being duly sworn, states that he or she is the Name of Corporate Officer, of Title of Corporate Officer Name of Corporation 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 own knowledge, and that the Application is made at the direction of the Board of Directors of the Corporation. Authorized Signature Date Sworn to before me this day of, 20 Notary Public Person assisting in completing the Application: Signature NOTE: Applicant must also sign page 17 Print Name Telephone Number Mail Form to: County of Muskegon Administration Unified DBE Opportunity Advisory Committee c/o Muskegon County Purchasing Department 141 E. Apple Avenue Muskegon, MI PLEASE READ THIS ENTIRE ITEM CAREFULLY!! Only the Signature of the owner of a sole proprietorship, a partner of a partnership or the president of a corporation is acceptable. (For a partnership, only a General Partner may sign, the signature of a Limited Partner is not acceptable.) When completed, the entire application must be notarized. 18