Page 1 of 10 STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION TALLAHASSEE, FLORIDA APPLICATION FOR SMALL BUSINESS CERTIFICATION (SBC) Mail Completed Forms To: FAMU 2035 East Paul Dirac Drive Suite 130, Morgan Building Tallahassee, Florida 32310 Telephone: (850) 561-2393 Toll Free: (800) 226-3881 Fax: (850) 561-2395
Page 2 of 10 IMPORTANT NOTICE APPLICANTS FOR SMALL BUSINESS CERTIFICATION ARE HEREBY NOTIFIED THAT INTENTIONAL INCLUSION OF FALSE, DECEPTIVE OR FRAUDULENT STATEMENTS ON THIS APPLICATION CONSTITUTES FRAUD. FURTHERMORE, YOU ARE HEREWITH NOTIFIED THE STATE OF FLORIDA CONSIDERS SUCH ACTION ON THE PART OF THE APPLICANT TO CONSTITUTE GOOD CAUSE FOR DENIAL, SUSPENSION, OR REVOCATION OF A CERTIFICATION BY THE STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION EQUAL OPPRTUNITY OFFICE.
Page 3 of 10 NOTICE TO APPLICANTS FOR THE SMALL BUSINESS CERTIFICATION (SBC) PLEASE BE ADVISED THAT THIS APPLICATION MUST BE COMPLETE WITHIN ITSELF WITHOUT REFERENCE TO ANY PREVIOUS APPLICATION OR STATEMENT. ALL SECTIONS OF THE APPLICATION FORM SHALL BE COMPLETED. IF ANY OF THE REQUESTED INFORMATION DOES NOT APPLY, IT SHALL BE INDICATED AS "NONE" OR "N.A." AS APPLICABLE. FAILURE TO MAKE ENTRIES IN EVERY SECTION OF THIS APPLICATION WILL DELAY PROCESSING UNTIL THE INFORMATION IS PROVIDED TO THE DEPARTMENT.
Page 4 of 10 DEPARTMENT USE ONLY Approved: Yes By: No Date 1. This application must be printed in ink or typewritten. IMPORTANT BEFORE ATTEMPTING TO FILL IN THIS FORM READ CAREFULLY AND ADHERE TO THE FOLLOWING 2. Each item must be set forth in full, and all explanations and documentation requested must be given in detail. 3. Failure to fill in any item will cause delay because the application will be returned for completion. 4. Do not substitute a different form. No other form or statement will be accepted. 5. Do not cut your statements short. If sufficient space is not provided, insert additional pages. GENERAL INFORMATION If a significant change in the structure of your firm occurs, such as a change of ownership, incorporation of a nonincorporated firm or any change in the officers or the name of your firm, this information shall be certified to the Department within 30 days. The undersigned hereby authorize(s) and request(s) any person, firm or corporation to furnish any pertinent information requested by the State of Florida Department of Transportation deemed necessary to verify the statements made in this application or regarding the ability, standing and general reputation of the applicant. DATED AT Name of Organization This day of 20 By: Title of Person Signing
Rule 14-79.006, F.A.C. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION SMALL BUSINESS CERTIFICATION 275-030-071 Page 5 of 10 DATE: NAME OF FIRM: ADDRESS OF FIRM: (Home Office) (No. & Street) (City) (State & Zip) MAILING ADDRESS: (No. & Street) (City) (State & Zip) BUSINESS PHONE NUMBER(s): CONTACT PERSON: (Bus/Phone) (Res/Phone) 1. DATE FIRM WAS ESTABLISHED: (Month) (Day) (Year) 2. COMPANY'S FEDERAL I.D. NUMBER: OR OWNER'S SOCIAL SECURITY NUMBER: # # 3. Does the firm hold a current Section 8(a) certification from the Small Business Administration? Yes No If yes, supply documentation. 4. NATURE OF BUSINESS: Specify major services/products, (example: fencing, barricade, engineering consultant). 5. MINORITY GROUP STATUS: Specify the minority group and percentage of ownership of the person(s) who own(s) and controls 51% or more of the firm: BLACK AMERICAN % ASIAN-INDIAN AMERICAN % HISPANIC AMERICAN % NATIVE AMERICAN % ASIAN-PACIFIC AMERICAN % WOMEN % 6. TYPE OF OWNERSHIP: (Check One) Corporation Partnership Sole Proprietorship
Page 6 of 10 7. Management of Firm: Identify each officer of the firm (by title) and state his/her current employment, or association with other businesses. TITLE NAME EMPLOYED BY PRESIDENT VICE PRESIDENT SECRETARY TREASURER 8. Identify those individuals (owners and non-owners) who direct or cause the direction of the management and policy decisions in the following areas. Policy Making Financial Decisions Hiring and Dismissal of Personnel 9. Identify those individuals (owners and non-owners) who make the day to day decisions on matters of management, policy, and operation. Decision to bid on a job Job Estimating Purpose of Equipment Supervision of Field Operations
Page 7 of 10 10. Identify those individuals (owners and non-owners) who carry out the following functions in the firm. Signs the payroll Signs for Surety Bonds & Insurance 11. Identify areas where a need for technical assistance exist. 12. Has the firm ever failed to complete any work awarded in a contract? Yes No If yes, explain: 13. State the approximate dollar value of the company. $. 14. Identify the firm's current bonding company, bank, and sources of letters of credit. BONDING COMPANY (Name & Address) BANKING INSTITUTION (Name & Address) LETTERS OF CREDIT (Name & Address) 15. Specify the firm's bonding limit. $ Specify the firm's total credit limit. $ 16. Identify all current sources (internal & external) and amounts of money loaned to the firm. SOURCE (Name & Address) DOLLAR AMOUNT PURPOSE
Page 8 of 10 17. Specify the gross receipts of the firm, including affiliates for the last three (3) years. (a) Year ending (b) Year ending (c) Year ending Total Receipts Total Receipts Total Receipts You may voluntarily provide copies of your Federal Income Tax Returns as supporting documentation. 18. List the six (6) largest projects, in dollar amount, completed by the firm during the last year. DOLLAR AMOUNT SCOPE OF WORK DATE CITY/STATE NAME AND ADDRESS OF CONTRACTOR OR FIRM 19. State the specific work and approximate dollar amount of work completed or presently underway for the Florida Department of Transportation for the past three (3) years. Who were the prime contractors? 20. MAJOR CUSTOMERS: Company City State
Page 9 of 10 NOTICE THE FOLLOWING ITEMS ARE TO BE INCLUDED & ATTACHED AS DOCUMENTATION: 1. A list of the firm's current full-time and part-time employees by name and length of service. 2. Complete financial statements for the last 3 years including a current financial statement. A financial statement includes but is not limited to the following documents: A balance sheet, an income statement, a statement of retained earnings, a statement of changes in financial position, and notes. If the firm has any affiliates, consolidated financial statements must be included. 3. Attach a list of equipment owned and/or leased by the firm. (Attach a copy of registration, title, serial number and the purchase and/or lease agreements for each of the items of equipment.) 4. Copies of the annual reports submitted to the Department of State, Division of Corporations for the previous three years. 5. Detailed resumes of the owners, directors and/or officers of the firm. 6. A copy all of licenses to do business. 7. Copy of authorization from the Department of State to transact business in the State of Florida, if the corporation is not a Florida corporation.
Rule 14-79.006, F.A.C. 275-030-071a Page 10 of 10 AFFIDAVIT The undersigned swears that the foregoing statements are true and correct and include all material information necessary to identify and explain the operations of, as well as the ownership thereof. Further, the undersigned agrees to provide through the prime contractor or, if no prime contractor, directly to the grantee current, complete and accurate information regarding actual work performed on any FDOT project, the payment therefore and any proposed changes, if any, of the foregoing arrangements and to permit the audit and examination of books, records and files of the named firm. Furthermore, I understand that I may not: (a) Fraudulently obtain, retain, attempt to obtain nor aid another in fraudulently obtaining or retaining or attempting to obtain small business certification. (b) Willfully make a false statement, whether by affidavit, report, or other representation, to a state official or employee for the purpose of influencing the certification or denial of certification of any entity as a small business. (c) Willfully obstruct, impede, or attempt to obstruct or impede any state official or employee who is investigating the qualifications of a business entity which has requested certification as a small business. Any material misrepresentation will be grounds for initiating action under Federal or State laws concerning false statements. SIGNATURE: NAME: TITLE: DATE: CORPORATE SEAL (Where Appropriate) Date: STATE OF COUNTY OF Sworn to and subscribed before me this day of, 20 by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. State of (Notary's printed name) My commission expires