SUPPLIER CLEARINGHOUSE REVERIFICATION APPLICATION FORM For free assistance, please call the Clearinghouse: San Francisco (415) 928-6892 Toll Free: (800) 359-7998 Do Not Use This Form Unless Previously Verified by the Clearinghouse 1. Verification Order Number (+): Federal Tax ID Number*: BUSINESS IDENTIFICATION (+) For which status are you applying? MBE WBE WMBE Business Name (+) Phone Number (+) Primary Business Location (+) ( ) Fax Number ( ) NUMBER STREET CITY COUNTY STATE ZIP CODE NUMBER STREET Mailing Address* (if different) CITY STATE ZIP CODE E-Mail & Website Contact Person (+) Owner/Officer* (List any additional owners in Section 3.) 2. Has. any ownership. or control of business changed since last verification by the Clearinghouse? Y N If yes, explain: 3. Please complete the following regarding ownership, Board of Directors and/or Officers (use separate sheet if needed).* Identify ALL persons & firms who own 5% or more of the business, as well as all officers, directors & key personnel. Name % Owned Ethnicity Gender (M/F) Title Gross Revenue* (last fiscal year): Bonding Company*: Number of Employees* (from whom FICA is deducted): Bonding Limit*: 4. BUSINESS SPECIALTY (+) Provide a brief description of products/services you provide: (+) * Field may be made available to the general public. Page 1 Field maintained in Clearinghouse database only. Copyright California Public Utilities Commission, May 1, 1996 rev10/05
5. Standard Industrial Classification Codes. List corporate-wide primary SIC code first. (+) A full listing of SIC codes may be obtained from the U.S. Department of Labor Internet Web site at http://www.osha.gov/oshstats/sicser.html or please call the Clearinghouse for assistance. 6. BUSINESS LOCATIONS/BRANCHES* How many business locations/offices does your firm have? Please list business locations/branches by City, County, number of employees on payroll (from whom FICA is deducted) in each location, SIC Codes describing the primary work in each location, and the date your ownership was established. Zip Code City No. of employees Primary SIC Code Date established Zip Code City No. of employees Primary SIC Code Date established Zip Code City No. of employees Primary SIC Code Date established (use separate sheet for additional locations, if needed) 7. Is your firm currently certified by another agency?* (see instruction for acceptable agency) If yes, please complete the following and submit a copy of the certificate with your completed application. Agency Expiration Date YES NO 8. Please indicate your business type (+) You must submit the most currently filed copies of the following documents. ALL INCOME TAX RETURNS MUST BE SUBMITTED IN FULL AND INCLUDE ALL SUPPORTING SCHEDULES AND STATEMENTS Sole Proprietor: Bank Signature Card Fed Tax Return - 1040 Form w/ 1040 Schin full with W2 and 1099 statements Partnership/LLC: Bank Signature Card Form 1065 in full with all schedules Last Meeting Minutes Corporation: Bank Signature Card Form 1120 or 1120S in full w/all sched. Last Shareholder/Board Minutes (+) Only business type information will be made available to the general public; all documents will be kept confidential pursuant to the Participation Agreement. AFFIDAVIT I/We, the undersigned, swear that all the information provided by me/us in this Reverification Application Package, including all supporting documentation submitted by me/us, is true and correct. I/We have read Section 8285 of the Public Utilities Code, State of California, contained in the application package, and understand the penalties for violation of this code. I/We have read and agree to the Participation Agreement contained in the application package and agree to release any documents or information required by the Supplier Clearinghouse to determine WMBE eligibility. Additionally, the Supplier Clearinghouse may conduct an on-site field audit of this business at any time during the application and/or eligibility periods to verify eligibility. I/We understand further that it is my/our responsibility to notify the Clearinghouse within thirty (30) days of any change of ownership, operation, or control in the business herein applying for Clearinghouse WMBE verification. Failure to do so may be cause for reapplication and/or determination of ineligibility. Name of Individual (print) Signature Title/Firm Date Page 2
Supplier Clearinghouse Supplier Diversity Program Public Utilities Commission State of California VERIFICATION RENEWAL (Re-verification Application Package) IMPORTANT: Please read these instructions carefully to avoid delays. The attached application form is being sent to you under the provision of General Order 156 of the California Public Utilities Commission (CPUC) that requires verified participants to submit a verification form at least once every three years. Your completion of the form is required in order to maintain your participation. Clearinghouse verification is valid for a three-year term, (with the exception of those firms verified under the Comparable Agency Verification procedure described below). WMBEs are required to reapply for verification every three years. Effective February 1, 1991,the (WMBE) Supplier Clearinghouse implemented a streamlined "Comparable Agency Verification (CAV) procedure. Under this procedure, businesses, which have been certified as Women Business Enterprises (WBEs), Minority Business Enterprises (MBEs), or Disadvantaged Business Enterprises (DBEs) by any of the Comparable Agencies may apply for WMBE re-verification to the Clearinghouse by simply submitting the following documents a fully executed Supplier Clearinghouse Re-verification Application ; and a copy of a current letter or certification, which grants WBE, MBE, or DBE (not SBE and must be a woman/minority) status from any of the accepted agencies. No other documents are needed. However, effective February 26, 2004, the CPUC has given the Clearinghouse permission to refrain from from automatic acceptance of a CAV if there is reason to believe that it may not meet Clearinghouse standards. In that case, request for further documentation will be made and may include an interview before making a a reccommendation to the CPUC, which has the final say on verification or denial. This applies to renewals as well Please note that Clearinghouse verification under this procedure is valid for the period specified by the comparable agency, up to a maximum of three years. We accept only the following agencies: National Minority Supplier Development Council(NMSDC) Women's Business Enterprise National Council (WBENC) U.S. Small Business Administration (SBA) 8(a) OR SDB programs only Please note that no action will be taken on an application for re-verification until the Clearinghouse has received all required data and documentation. Additionally, the Clearinghouse reserves the right to request additional information and documentation it deems necessary to process an application and/or conduct an on-site visit with an applicant. An applicant who fails to supply information cannot be verified. The Clearinghouse will contact an applicant twice by letter after the applicant s initial submission if any further information is needed. Failure of an applicant to respond in a timely fashion will result in the closing of the applicant s file. Applicants reapplying for verification may be required to follow all original application procedures. Answers to questions or assistance may be obtained by contacting the Supplier Clearinghouse at the address or telephone numbers listed below. SUPPLIER CLEARINGHOUSE - Administered by ASIAN, Inc. pursuant to PUC General Order 156 rev 5/07 1167 Mission Street, 4th Floor San Francisco, CA 94103 Toll Free: 800-359-7998 Tel: 415-928-6892 Fax: 415-921-0182
INSTRUCTIONS AND PARTICIPATION AGREEMENT FOR RE-VERIFICATION The following are items that are frequently asked about. Some are self-explanatory and we don t discuss them further here. Note that each of the following numbers refers to the sections of the application. 1. Verification Order Number (VON): the 8-figure number that appears on your reminder letter (e.g., 94AN1001) Status being applied for: MBE is minority business enterprise WBE is woman (non-minority) business enterprise WMBE is minority and woman business enterprise (i.e., a business owned and managed by minority women) We may assign you to a different status if it seems appropriate. Please be sure to include ZIP codes, and both e- mail and web page addresses, if any. 2. Has any ownership or control changed? Common examples of changes would be: change from a sole proprietorship to a partnership or a corporation (or back to a proprietorship); change of partners or stockholders; a new partnership agreement; or new management, including changes to the Board of Directors or officers of a corporation. The above list does not cover all the possibilities; when in doubt, tell us. 3. Ownership: list ALL owners of more than 5% of the company, even if there is only one. List ALL directors and ALL officers if it is a corporation. For each person, give titles (example, stockholder, director, or president). If the same person is owner, director, and officer, all the titles can go on the same line. Employees: anyone on the payroll, not the proprietor or partners if those people are not paid through payroll. If you are a personnel placement agency, show only the number of your regular staff, not all the temporaries. Bonding: applies mainly to construction firms. If you do not have it, please leave blank. 4. Business specialty: this item should be descriptive (not an advertisement). If you do more than one thing, list the most important one first. 5. SIC codes: SIC codes are established by the U.S. Office of Management and Budget as a way of classifying all industries. The Clearinghouse uses the 1987 SIC manual, which is the most recent one published, as our reference in reviewing SIC codes. A full listing of SIC codes may be obtained from the U.S. Department of Labor Internet Web site at http://www.osha.gov/oshstats or you may call the Clearinghouse for assistance. Put down only as many as apply you don t have to fill all the boxes. If you use multiple codes, you should list first the code that corresponds to your principal line of work. If you can t find an appropriate code, leave it blank, and we will assign one, using the information you provided in section number 4. The SIC code only helps to identify your firm; it does not affect your chances for re-verification. 6. Please list business locations, even if there is only one, plus the rest of the information requested. 7. Are you certified by another agency? If so, include a copy of your certificate. (You do not need to include a copy of OUR certificate because we already know about that one.) Please be aware that we may accept certificates from only certain agencies, and the certificates must be currently valid. If we certify you using another agency s certificate (the comparable agency verification process) we will not certify you beyond that agency s expiration date. 8. Please indicate your business type. If you gave us a valid comparable agency certificate (section 7) you can now go directly to the affidavit. If you do NOT give us another agency s certificate, we need the documents indicated for your type of business. Documents are maintained under strict confidentiality pursuant to the Participation Agreement (see below). For the bank signature card, you may substitute a letter from your banker listing the names of all persons authorized to sign and the number of signatures required. Tax forms: please include the ENTIRE Federal returns. With the 1040 we also want W-2s and 1099s for all family members, whether or not engaged in the business. Please do not delete or black out any numbers. You do not need to include state tax returns. For a corporation, please provide a copy of the most recent Board and shareholder meeting minutes. If you do not hold formal meetings (as, for example, when you are the sole stockholder) give us a statement explaining that. Instructions - Page 2
Affidavit: please sign and send us the original signed copy. It does not need to be notarized. Please do not fax the application. (You may fax unsigned documents if we ask for them later.) Where to return your application: Send application & all supporting documents to the San Francisco office since we have closed our North Hollywood office effective July 31, 2005: 1167 Mission St., 4th Floor San Francisco, CA 94103. We will send an acknowlegement letter within 2-3 weeks from when we receive the application.we strongly recommend that you send the application with some type of return receipt.we cannot guarantee receiving an application if sent only by regular mail. Note: we look carefully at reverification applications, and may ask for other documents, conduct a phone interview, or make a site visit. Re-verification is not automatic or guaranteed. Until a determination is made, the firm's status will be "verified pending renewal." A final note: we will send you three reminder letters when your verification is about to expire. However, if you have moved, the notices may not reach you. To avoid any delays, NOTIFY US OF YOUR NEW ADDRESS WHENEVER YOU MOVE. You must also inform us of any change in company structure, management, or ownership pursuant to the Participation Agreement. Please read the following Participation Agreement carefully. PARTICIPATION AGREEMENT It is important that you fully understand the terms upon which WMBE verification is granted by the Clearinghouse. Verification as a woman, or minority-owned business enterprise ("WMBE") imposes requirements that must be adhered to during the period that verification is valid ("Verification Period"). Your eligibility to become a verified WMBE is contingent upon reading the terms set out below and acknowledging this Agreement in the application form. I/We acknowledge that my/our application for re-verification as a WMBE is subject to and contingent upon the following: 1. I/We understand that verification as a WMBE by the Clearinghouse confirms that the ownership, management and control of my/our company meets the WMBE eligibility standards set out in General Order 156 and applicable Clearinghouse guidelines. I/We also understand that WMBE verification does not constitute an endorsement of my/our company's technical capabilities or guarantee placement on utility bid lists or award of any utility contracts. 2. I/We understand that, if my/our company is verified, the terms of this Agreement will apply during the Verification Period. I/We also understand that failure to comply with any of the terms below can result in the automatic rejection of my/our verification application or the revocation of my/our WMBE verification if my/our company is granted WMBE status by the Clearinghouse. (a) I/We agree to submit to the Clearinghouse all documentation that may be requested in order to determine my/our WMBE eligibility. This may include, but not be limited to, all documents requested in the application form and any additional documentation required by the Clearinghouse to clarify statements made in the application or to clearly evidence WMBE eligibility. (b) I/We agree to notify the Clearinghouse within thirty (30) days following any change in the ownership, management or control of my/our company. (c) I/We agree that I/we will not knowingly or willfully submit to the Clearinghouse information that is false, misleading or incorrect. (d) I/We agree to submit to the Clearinghouse, within the required timeframe, proof of continued WMBE eligibility. upon expiration of the three-year Verification Period (if verified under the full Supplier Clearinghouse verification procedure); or upon expiration of certification by a comparable agency (if verified under the Comparable Agency Verification procedure); and/or upon receipt of notice from the Clearinghouse that it has made a decision to reinvestigate my/our company's WMBE eligibility. 3. I/We understand that the Clearinghouse has the authority to reinvestigate, for good cause, my/our company's WMBE eligibility during the Verification Period. Instructions - Page 3
4. I/We agree to cooperate fully with the Clearinghouse staff in the conduct of on/off-site field audits,before or after WMBE verification, to determine the initial and/or continuing WMBE eligibility of my/our company. The field audit may include interviews and examination of business and personal records and any other information deemed necessary by the Clearinghouse staff. Failure to comply may result in a presumptive denial of WMBE verification. 5. I/We understand that if I/we cancel a scheduled field audit without good cause and without at least four (4) working days advance notice to the Clearinghouse, the Clearinghouse may not be able to schedule a new field audit due to fiscal or other constraints. Therefore, I/we understand that such cancellation may lead to a presumptive denial of WMBE verification if the Clearinghouse cannot determine the WMBE eligibility of my/our company without conducting a field audit. 6. I/We understand that WMBE verification by the Clearinghouse will automatically be revoked if my/our firm ceases doing business, is sold, or significant managment change occurs during the Verification Period. 7. I/We understand that the Clearinghouse has the authority to revoke my/our company's WMBE verification at any time during the Verification Period for good cause, including, but not limited to, failure to comply with any of the terms contained in paragraph 2 of this Agreement. 8. I/We understand that if my/our company is denied WMBE verification, neither its owner(s), officers, nor any key employee may reapply to the Clearinghouse for verification during the twelve (12) months following the date of final denial by the Clearinghouse. Notwithstanding the above, if I/my company rebuts any denial of verification through the Clearinghouse appeals process and exhausts its administrative remedies at the CPUC, and there has been a significant, demonstrable change in my/our company's ownership, management, and/or control, I/my company may reapply for verification within the 12-month period. 9. I/We understand that if my/our company is denied WMBE verification and if I/we do not file a complaint with the CPUC within ninety (90) days following the date of final denial by the Clearinghouse, my/our application will be deemed closed. 10. I/We understand that the Clearinghouse operator may release the following information to the public: Name of firm, address, and telephone number. Ethnicity of owner(s) and/or controlling members. Gender of owner(s) and/or controlling members. Name of the agency and party that performed a site visit, and date of site visit, if applicable. Name of the agency that conducted the verification process. Product or service categories. Geographical area. Type of ownership. Any additional local requirements met by the enterprise, if applicable. A record of actions by a participating state or local agency resulting in verification denial or deverification. 11. I/We understand that my/our entire verification file may be made available to other agencies which perform verification, as necessary to comply with Public Contract Code Sections 2050 through 2057. 12. I/We understand that, SUBJECT TO THE ABOVE, the Clearinghouse will seek to protect the confidentiality of information submitted as part of the verification and re-verification application process, including, but not limited to, the application forms, and any subsequent information as part of any protest, or verification procedure, to the extent permitted by law and the Agreement with the CPUC. The Clearinghouse and CPUC cannot be held liable for release of information pursuant to requests from participating utility companies, or parties authorized by the CPUC, or pursuant to any administrative, judicial or regulatory proceedings. 13. I/We understand that any applicant for Clearinghouse WMBE verification who misrepresents or falsifies information or documentation requested in this application process is subject to the penalties provided by Public Utilities Code, Section 8285: Any person or corporation, through its directors, officers, or agents, which falsely represents the business as a women or minority business enterprise in the procurement or attempt to procure contracts from electric, gas, and telephone corporations with gross annual revenues exceeding twentyfive million dollars ($25,000,000) and their commission-regulated subsidiaries and affiliates pursuant to this article, shall be punished by a fine of not more than five thousand dollars ($5,000), or by imprisonment in the county jail for not to exceed one (1) year or in the state prison for not to exceed five (5) years of its directors, officers, or agents responsible for the false statements, or both the fine and imprisonment (ADDED STATS. 1986, CH. 1269). Please keep this for your record. Instructions - Page 4