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Rev 201 1
COUNTY OF ERIE/CITY OF BUFFALO JOINT CERTIFICATION COMMITTEE
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 a
question completely, attach additional sheets as necessary. Use the
question number to identify any answer continued on an additional
sheet. Retain a copy of your entire application.
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.”)
Name:
Street:
City: ___________________________ State: ________________ Zip
Code: _______ “Doing Business As” (DBA) Name (Complete if firm does
business under an assumed or trade name that is different from its
legal name) Mailing Address (if different from above) Street: City:
_____________________________ State: _______________ Zip Code:
______ Business Phone Number: __________________ ext_____ Fax:
___________ Email: __________________________ Web Address:
___________________________ Federal Employer Identification Number
(EIN) or Social Security Number (A Federal EIN is required for most
business activities. For an application and/or additional
information, contact the United States Internal Revenue Service
website http://www.irs.gov. Sole Proprietorships may submit social
security number of the owner in lieu of the federal EIN.
_______________________________________ Name of Company’s
President, Chief Executive Officer, and Owner
_____________________________________________________ Name &
Title of Officer of the Firm who can be contacted during
application review process:
_____________________________________________________
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Rev 7/2010 2
1. Firm is applying for certification as:
Minority Business Enterprise (MBE) Women-Owned Business
Enterprise 2. Name & Position of all person(s) with ownership
interest. (Check all applicable. If no positions are held, state
“none.” **For Group Codes, above.) Name Position Group % Owned
Gender US Citizen/Permanent Code Resident Alien
_____________________ ____________ ______ ________ M F Yes No
_____________________ ____________ ______ ________ M F Yes No
_____________________ ____________ ______ M F Yes No
DEFINITIONS & GROUP CODE OF MBE AND WBE
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 WOMEN OWNED BUSINESS ENTERPRISE (WBE) A business
enterprise in which at least fifty-one percent (51%) is owned by
citizens or permanent resident aliens who are women. MINORITY
BUSINESS ENTERPRISE (MBE) A business enterprise in which at least
fifty-one percent (51%) is owned by citizens or permanent resident
aliens who meet the following definitions: Group Group Group Code
Name Definition 01 Black Persons having origins from any of the
Black, African racial
groups 02 Hispanic Persons of Mexican, Puerto Rican, Dominican,
Cuban, Central
or South American descent of either Indian or Hispanic origin,
regardless of race 03 Asian-Pacific Persons having origins from the
Far East, Southeast Asia or
the Pacific Islands 04 Asian-Indian Persons having origins from
the Indian subcontinent 05 Native American Persons having origins
in any of the original peoples of North
America 06 Non-Minority Persons whose culture or origin is other
than those defined
above
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Rev 7/2010 3
3. Are you currently involved in the bidding process or other
contract/purchase order negotiations with any governmental agency,
department, or authority?
Yes No
If Yes, please identify the agency, department, or authority.
_____________________________________________________________
4. Specify Type of Current Ownership
Sole Proprietorship ______________ Certificate of Trade Name on
file in ____________________ Date Established County
Partnership _______________ Business Certificate for Partners on
file in _______________ Date Established County
Corporation _______________ Certificate of Incorporation on file
in ___________________ Date Established County
LLC/LLP _______________ Certificate of Incorporation on file in
___________________ Date Established County
5. Did the business exist under a different type of business
ownership prior to the date indicated in question 4?
No If Yes, please explain
___________________________________________________
____________________________________________________________________________________
6. Has your Certification of Incorporation been amended?
No If Yes, please explain
___________________________________________________
____________________________________________________________________________________
7. Method of Acquisition (Check all applicable):
Started New Business Bought Existing Business Secured
Franchise
Secured Concession Inherited Business Merger or
Consolidation
Other: __________________________________________ Date of
Acquisition: ___________________________________
8. Please identify the cash and capital contributions to the
firm by those identified in question 7, including gifts, equipment,
loans, and expertise.
Contributor/Source Amount/Value Type of Contribution Date of
Contribution
____________ _________________ _________________ ____________
_________________ _________________ ____________ _________________
_________________
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Rev 7/2010 4
9. If the firm is a partnership, please complete for all
partners.
Name Total Amount/Value of Contribution Date of Ownership
___________________________ ___________________
___________________________ ___________________
___________________________ ___________________
10. If the firm is a corporation, please complete for all
shareholders.
Name/Contributor No. of Common or Amount Paid Date of
Contribution Shares Preferred when Purchased
________________________ ___________ __________ ___________
________________
________________________ ___________ __________ ___________
________________ ________________________ ___________ __________
___________ ________________
11. If a corporation, number of shares:
Common Authorized: __________________ Common Issued:
___________________ Preferred Authorized: _________________
Preferred Issued: ___________________
12. Gross Sales/Tax Returns. Please provide tax returns for the
last 3 years. (If in business for less than 3 years complete as
applicable.)
Amount Amount Amount ___________________ __________________
__________________
Current Year 20____ Last Year 20_____ Previous Year 20_____
13. Number of Employees (Provide average over the past
year).
Permanent Temporary Full-Time ___________ Full-Time _________
Part-Time ___________ Part-Time _________
14. If licensing, permits or accreditation is required to
conduct the business, please identify:
Type of License/Permit Issued By Issue Date Exp. Date
Holder/Registrant _______________________ ___________ __________
_________ _________________
_______________________ ___________ __________ _________
_________________ _______________________ ___________ __________
_________ _________________
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Rev 7/2010 5
15. Check all that best describes the business operation. (**For
definition see application instructions)
Construction-Related Customer Service Broker
Professional Service Manufacturer Supplier**
Retail Technical Service
Other
(Explain):________________________________________________________________
________________________________________________________________________________
16. Describe principle products/commodities sold, specialties or
services offered. (Please explain.)
________________________________________________________________________________
________________________________________________________________________________
17. Identify those individuals responsible for managerial
operations (State if owner or non-owner). *For Group Codes, see 2
Page.
Name & Title Gender Group Code Owner 1. Financial
Decisions
Name & Title Gender Group Code Owner
_________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 2.
Estimating Name & Title Gender Group Code Owner
_________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 3.
Preparing Bids Name & Title Gender Group Code Owner
_________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 4.
Negotiating Bonding Name & Title Gender Group Code Owner
_________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
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Rev 7/2010 6
5. Negotiating Insurance Name & Title Gender Group Code
Owner _________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 6.
Marketing & Sales Name & Title Gender Group Code Owner
_________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 7.
Hiring & Firing Name & Title Gender Group Code Owner
_________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 8.
Supervising Field Operations Name & Title Gender Group Code
Owner _________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 9.
Purchasing Equipment/Supplies Name & Title Gender Group Code
Owner _________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 10.
Managing & Signing Payroll Name & Title Gender Group Code
Owner _________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
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Rev 7/2010 7
11. Negotiating Contracts Name & Title Gender Group Code
Owner _________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No 12.
Signatories for Business Accounts Name & Title Gender Group
Code Owner _________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
____________________________________ M F __________ Yes No
18. 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
phone number.)
1. Office Staff Name & Position Other Firm Name &
Address Phone ____________________________
_____________________________ ___________________
____________________________ _____________________________
___________________ 2. Field/Supervisory Staff
Name & Position Other Firm Name & Address Phone
____________________________ _____________________________
___________________
____________________________ _____________________________
___________________
3. Estimator
Name & Position Other Firm Name & Address Phone
____________________________ _____________________________
___________________
____________________________ _____________________________
___________________ 4. Controller
Name & Position Other Firm Name & Address Phone
____________________________ _____________________________
___________________
____________________________ _____________________________
___________________ 5. Consultant (For firms involved in providing
consultant service or advisory service.)
Name & Position Other Firm Name & Address Phone
____________________________ _____________________________
___________________ ____________________________
_____________________________ ___________________
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Rev 7/2010 8
19. Does this firm share the following with any other firm? If
yes, please provide the other firm’s name, address, and phone
number.
1. Office Space Other Firm Name Address Phone
____________________________ _____________________________
___________________
____________________________ _____________________________
___________________ 2. Yard Space
Other Firm Name Address Phone
____________________________ _____________________________
___________________
____________________________ _____________________________
___________________ 3. Equipment (include rentals)
Other Firm Name Address Phone
____________________________ _____________________________
___________________
____________________________ _____________________________
___________________
20. List rented, leased, or owned warehouse, plant, yard, and
office facilities.
Facility Type Owner or Name of Lessor and/or rental agent If
rented or leased Amount of yearly payment ____________________
__________________________________ ___________________________
____________________ __________________________________
___________________________
21. List major equipment or machinery that is owned or leased by
the firm. Type Depreciated $ Value Acquisition Date Payment Terms
___________________ _______________________ ______________
___________________ ___________________ _______________________
______________ ___________________ ___________________
_______________________ ______________ ___________________
22. Do any principles, officers and/or owners of the firm have
an affiliation (i.e. business interest or employment)
with any other firm? Yes No If Yes, please complete the
following. Name of Person Firm Name & Address Phone Number
Nature of Business Nature of Affiliation ____________________
______________ ____________________ ________________
____________________ ______________ ____________________
________________ ____________________ ______________
____________________ ________________
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Rev 7/2010 9
23. Attorney for Firm
Name
____________________________________________________________________
Address
______________________________________________________________________
City ______________________________________State _____________
Zip Code__________
Phone Number: ________________________________________
24. CPA/Accountant for Firm
Name
____________________________________________________________________
Address
_______________________________________________________________________
City ______________________________________State _____________
Zip Code __________
Phone Number: ________________________________________
25. Has the firm applied for certification as an M/WBE with
another governmental agency, department or authority? Yes No If
Yes, please complete the following.
Agency Date Contact Person Phone Specify MBE
or WBE 1. Pending With ___________________ ____________
____________________ ______________ ___________ ___________________
____________ ____________________ ______________ ___________ 2.
Certified By ___________________ ____________ ____________________
______________ ___________ ___________________ ____________
____________________ ______________ ___________ 3. Registered By
___________________ ____________ ____________________
______________ ___________ ___________________ ____________
____________________ ______________ ___________
26. List the three largest accounts for which the applicant has
provided goods or services within the last two years. Firm Name
Phone Account Location of Duration Dollar Amount Performance
____________________________ _____________ ______________
______________ ________ ____________________________ _____________
______________ ______________ ________
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Rev 7/2010 10
27. Identify Bank(s) where firm’s accounts are maintained.
Bank Name Address Contact Account Type Account Number
____________________________ _____________ ______________
______________ ________ ____________________________ _____________
______________ ______________ ________
28. Do you have a Line of Credit? Yes No If Yes, please
identify. Source Limit Name of Guarantor(s)
_____________________________ ________________________
________________________________ _____________________________
________________________ ________________________________
29. List major current creditors and/or lenders and types of
investments and/or loans in the firm.
Name of Creditor/Lender Type of Investment Dollar Value of
Investment Credit/Loan Terms/Credit/Loans
____________________________ ________________________
____________________ ____________________________
________________________ _____________________
30. 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 % Ownership ____________________________
______________________________________ _______________
____________________________ ______________________________________
_______________
31. Is the firm bonded? Yes No Bonding Company
________________________________________________________________________
Address
_______________________________________________________________________________
City _____________________________ State ________________ Zip Code
_______ Phone Number ____________________ Contact Person
____________________________ Type _____________________________
Limit _________________________________
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Rev 7/2010 11
SUPPORTING DOCUMENTS A. REQUIRED FOR ALL APPLICANTS Attach
copies of the following, if applicable. Please indicate documents
submitted by checking appropriate boxes. Applicant must provide
copies of the completed application to all five members of the JCC
Committee NOTE: If appropriate documents are not submitted AND no
written explanation is given, the application will be returned to
you.
1. Resumes of all principles, partners, officers, and/or key
employees of the firm as per questions 2, 13, and 17. Show home
address and phone number, education, training, and employment
dates.
2. Bank signature card, bank resolution, or letter from the bank
identifying persons authorized to conduct transactions, level
of
authority and limitations, if any.
3. Current Financial Statement. (Balance Sheet and Profit &
Loss Statement.)
4. Most recent two years’ Federal, State, and City tax returns
including all schedules (e.g. Schedule K-1), where applicable.
5. Proof of sources of capitalization/investments.
6. Proof of ethnicity (i.e. Birth Certificate, Baptismal
Certificate, Picture ID, etc.)
7. Proof of US Citizenship (i.e. Birth Certificate, US Passport,
Naturalization Certificate, etc.)
8. Proof of permanent resident alien status (i.e. permanent
resident “green” card).
9. Lease Agreements per questions 20 and 21.
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. Out-of-state firms should attach a
copy of their home state certification, if similar process
exists.
14. Written request for exemption from disclosure regarding
trade secrets.
15. If Out-of-state firm, the Authority to Do Business In New
York State.
B. REQUIRED FOR SOLE PROPRIETORSHIP (Attach copies of the
following: Please indicate documents submitted by a check
mark.)
1. Copy of Certificate Trade Name or Business Trade Name filed
with County Clerk (If doing business under an assumed name) C.
REQUIRED FOR PARTNERSHIP AND A JOINT VENTURE PARTNERSHIP (Attach
copies of the following: Please indicate documents submitted by a
check mark.)
1. Business Certificate
2. Partnership Agreement
3. Buy-out Rights
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Rev 7/2010 12
SUPPORTING DOCUMENTS
D. REQUIRED FOR A CORPORATION (Attach copies of the following,
if applicable. Please indicate documents submitted by a check
mark.)
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:
Stock Options Shareholder Agreements Shareholder voter rights
Restriction on the disposal of stock loan agreements Facts
pertaining to the value of shares Buy-out rights Restriction on the
control of the corporation E. REQUIRED FOR ALL LLC/LLPs (Attach
copies of the following, if applicable. Please indicate documents
submitted by a check mark.)
1. Certificate of Registration
2. Articles of Organization
3. Operating Agreement
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Rev 7/2010 13
VERIFICATION STATE OF _______________ ) COUNTY OF _____________
) SS: A) ___________________________________________, being duly
sworn, states he or she is the owner of (or a partner 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. B) _______________________________________, being
duly sworn, states that he or she is the Name of Corporate Officer
_______________________________________, of
_________________________________, Title of Corporate Officer Name
of Corporation the enterprise 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.
______________________________________ ________________________
Signature Date Sworn to before me this ______ Day of
______________, 20__ __________________________ Notary Public
Person assisting in completing the Application
________________________________ Print Name
__________________________________ _______________________
Signature Phone Number
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1
ATTACHMENT A: JCC - MWBE CERTIFICATION INDIVIDUAL PERSONAL NET
WORTH AFFIDAVIT
County of Erie and City of Buffalo – Joint Certification
Committee
Each individual owner relied upon for certification as a
minority or women‐owned business enterprise
(hereinafter “MWBE”) must complete this form and provide the
applicable supplemental
documentation as referenced below as part of the application for
certification or recertification.
The personal net worth of each individual upon which
certification is relied upon cannot exceed 3.5
million dollars. For certification purposes, personal net worth
shall mean the aggregate adjusted net
value of the assets of an individual remaining after total
liabilities are deducted. Personal net worth
includes the individual's share of assets held jointly with said
individual's spouse but does not include
the individual's ownership interest in the certified minority
and women‐owned business enterprise, the
individual's equity in his or her primary residence, or up to
five hundred thousand dollars of the present
cash value of any qualified retirement savings plan or
individual retirement account held by the
individual less any penalties for early withdrawal.
I, _________________, being duly sworn state that my social
security number is: ______ ‐ ____ ‐
_______ and I am a woman or a member of a minority group as
defined in Article 15‐A of the Executive
Law. I own ______ percent of the equity in
______________________________, the business applying
for certification or re‐certification as an M or WBE with the
JCC. I have read the definition of net worth
set forth in the statement above, and have calculated my net
worth to be $_______________.
Further, I understand that I am required to provide, with this
affidavit, a true, executed copy of my
submitted federal and state personal tax returns including all
statements and schedules as filed for the
prior taxable year. I also understand that in the event my
personal net worth exceeds 3.5 million dollars
at the time of this application, I am also required to submit a
complete Personal Financial Statement or
Worksheet. I understand the tax returns I have submitted to the
Joint Certification Committee as part of
the certification or re‐certification process must be true and
correct copies of my personal tax returns
and include all schedules, statements and amendments which I
have submitted to the IRS and the state
or, in the event that I have paid taxes in multiple
jurisdictions, states where I have filed my most recent
state income taxes. By signing below I am attesting that I am
providing this as part of the application for
certification or re‐certification, and acknowledge any false
statement made by the applicant will result in
the denial of certification and is punishable as a Class E
Felony under Section 175.35 of the Penal Law.
_____________________________________
__________________________________ (Signature)
(Print) State of New York, County of __________________. On this
________ day of __________20____,
before me appeared
(Name)____________________________________________________________to
me personally known, who being duly sworn, properly did execute
the foregoing affidavit and did state
that s/he was properly authorized by(Name of Firm)
_________________________________________
to execute the affidavit and did so as his or her free act and
deed.
Notary Public__________________________________
Commission Expires____________________________________
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2
Attachment B: JCC MWBE CERTIFICATION SMALL BUSINESS
AFFIDAVIT
County of Erie and City of Buffalo – Joint Certification
Committee
Each applicant firm applying for certification as a minority or
women-owned business enterprise
(hereinafter “MWBE”) must complete this form and provide
supporting documentation upon request as
part of the application for certification or recertification.
All applicant firms must be a business which
has a significant business presence in the State, be
independently owned and operated, and not
dominant in its field, and in no event employs more than three
hundred people.
I, ________________________, being a duly sworn authorized
representative and owner of the
applicant firm________________________________________ state
that my firm employs _______ full
time equivalent employees and in no event exceed three hundred
people. I attest my firm is not
dominant in its field, and has a significant business presence
in the state of New York as required under
Article 15-A of the Executive Law. I understand that I may be
required to provide, with this affidavit, a
true, executed copy of the applicant firms federal and state tax
returns including all statements and
schedules as filed for the prior taxable year, payroll records,
W2s and other related documentation to
support the claims set forth in this affidavit.
By signing below I am attesting that I am providing this as part
of the application for certification or re-
certification, and acknowledge any false statement made by the
applicant will result in the denial of
certification and is punishable as a Class E Felony under
Section 175.35 of the Penal Law.
_____________________________________
__________________________________
(Signature) (Print)
State of New York, County of __________________. On this
________ day of __________20____,
before me appeared
(Name)____________________________________________________________to
me personally
known, who being duly Sworn, properly did execute the foregoing
affidavit and did state that s/he was
properly authorized by (Name of Firm)
____________________________________________________________to
execute the affidavit and
did so as his or her free act and deed.
Notary Public__________________________________
Commission Expires_____________________________
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County of Erie and City of Buffalo Joint Certification
Committee
MBE/WBE/Dual Disclosure Affidavit
The Following Agencies are voting Members of the Committee:
Please return completed application and
documents to the following voting members of the Joint MBE/WBE
Certification Committee.
EMAILS WILL NOT BE ACCEPTED.
Timothy Hogues Acting Director
County of Erie, Division of Equal Employment Opportunity 95
Franklin Street, Room 625
Buffalo, New York 14202 (716) 858-7542
E-Mail: [email protected]
Fatima Morrell, Ed.D. Assistant Superintendent of Curriculum,
Assessment, and Instruction
Buffalo City School District City Hall Room 2008 65 Niagara
Square
Buffalo, New York 14202 (716)-816-3584
Fax (716) 851-3746 E-Mail: [email protected]
Shatorah Donovan Chief Diversity Officer
203 City Hall 65 Niagara Street
Buffalo, New York 14202 (716) 851-4920
E-Mail: [email protected]
Ron Brown Secretary to General Manager
Buffalo Sewer Authority 1038 City Hall
Buffalo, New York 14202 (716) 851-4664 ext. 4224
E-Mail: [email protected]
Willie Morris Contract Compliance Officer
Buffalo Municipal Housing Authority 320 Perry Street
Buffalo, New York 14204 (716) 855-7580 ext. 308
E-Mail: [email protected]
Application for CertificationMBE Application_Certification
changes 7 29 15 pgs 13JCC Rules and Regulations Revision Doc
November 2014 approved to form (1)State attachment copyCounty of
Erie and City of Buffalo Joint Certification Committee
County of Erie and City of Buffalo Joint Certification
Committee
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Name___Title_1[0]: Name___Title_2[0]: Name___Title_3[0]:
Name___Title_1_2[0]: Name___Title_2_2[0]: Name___Title_3_2[0]:
Name___Title_1_3[0]: Name___Title_2_3[0]: Name___Title_3_3[0]:
Name___Title_1_4[0]: Name___Title_2_4[0]: Name___Title_3_4[0]:
#field[25]: Off#field[26]: Off#field[27]: Off#field[28]:
Off#field[29]: Off#field[30]: Off#field[31]: Off#field[32]:
Off#field[33]: Off#field[34]: Off#field[35]: Off#field[36]:
Off#field[37]: Off#field[38]: Off#field[39]: Off#field[40]:
Off#field[41]: Off#field[42]: OffGroup_Code_1[0]: Group_Code_2[0]:
Group_Code_3[0]: #field[46]: Off#field[47]: Off#field[48]:
OffGroup_Code_1_2[0]: Group_Code_2_2[0]: Group_Code_3_2[0]:
#field[52]: Off#field[53]: Off#field[54]: OffGroup_Code_1_3[0]:
Group_Code_2_3[0]: Group_Code_3_3[0]: #field[58]: Off#field[59]:
Off#field[60]: Off#field[61]: Off#field[62]: Off#field[63]:
OffGroup_Code_1_4[0]: Group_Code_2_4[0]: Group_Code_3_4[0]:
#field[67]: Off#field[68]: Off#field[69]: Off#field[70]:
Off#field[71]: Off#field[72]: Off#field[73]: Off#field[74]:
Off#field[75]: Off#field[76]: Off#field[77]: Off#field[78]:
Off#field[79]: Off#field[80]: Off#field[81]: Off#field[82]:
Off#field[83]: Off#field[84]: Off
Page6[0]: Name___Title_1_5[0]: Name___Title_2_5[0]:
Name___Title_3_5[0]: Name___Title_1_6[0]: Name___Title_2_6[0]:
Name___Title_3_6[0]: Name___Title_1_7[0]: Name___Title_2_7[0]:
Name___Title_3_7[0]: Name___Title_1_8[0]: Name___Title_2_8[0]:
Name___Title_3_8[0]: Name___Title_1_9[0]: Name___Title_2_9[0]:
Name___Title_3_9[0]: Name___Title_1_10[0]: Name___Title_2_10[0]:
Name___Title_3_10[0]: #field[18]: Off#field[19]: Off#field[20]:
Off#field[21]: Off#field[22]: Off#field[23]: Off#field[24]:
Off#field[25]: Off#field[26]: Off#field[27]: Off#field[28]:
Off#field[29]: Off#field[30]: Off#field[31]: Off#field[32]:
Off#field[33]: Off#field[34]: Off#field[35]: Off#field[36]:
Off#field[37]: Off#field[38]: Off#field[39]: Off#field[40]:
Off#field[41]: Off#field[42]: Off#field[43]: Off#field[44]:
Off#field[45]: Off#field[46]: Off#field[47]: OffGroup_Code_1_5[0]:
Group_Code_2_5[0]: Group_Code_3_5[0]: #field[51]: Off#field[52]:
Off#field[53]: OffGroup_Code_1_6[0]: Group_Code_2_6[0]:
Group_Code_3_6[0]: #field[57]: Off#field[58]: Off#field[59]:
OffGroup_Code_1_7[0]: Group_Code_2_7[0]: Group_Code_3_7[0]:
#field[63]: Off#field[64]: Off#field[65]: OffGroup_Code_1_8[0]:
Group_Code_2_8[0]: Group_Code_3_8[0]: #field[69]: Off#field[70]:
Off#field[71]: OffGroup_Code_1_9[0]: Group_Code_2_9[0]:
Group_Code_3_9[0]: #field[75]: Off#field[76]: Off#field[77]:
Off#field[78]: Off#field[79]: Off#field[80]: OffGroup_Code_1_10[0]:
Group_Code_2_10[0]: Group_Code_3_10[0]: #field[84]: Off#field[85]:
Off#field[86]: Off#field[87]: Off#field[88]: Off#field[89]:
Off#field[90]: Off#field[91]: Off#field[92]: Off#field[93]:
Off#field[94]: Off#field[95]: Off#field[96]: Off#field[97]:
Off#field[98]: Off#field[99]: Off#field[100]: Off#field[101]:
Off#field[102]: Off#field[103]: Off#field[104]: Off#field[105]:
Off#field[106]: Off#field[107]: Off
Page7[0]: Name___Title_1_11[0]: Name___Title_2_11[0]:
Name___Title_3_11[0]: Name___Title_1_12[0]: Name___Title_2_12[0]:
Name___Title_3_12[0]: #field[6]: Off#field[7]: Off#field[8]:
Off#field[9]: Off#field[10]: Off#field[11]: OffGroup_Code_1_11[0]:
Group_Code_2_11[0]: Group_Code_3_11[0]: #field[15]: Off#field[16]:
Off#field[17]: Off#field[18]: Off#field[19]: Off#field[20]:
OffGroup_Code_1_12[0]: Group_Code_2_12[0]: Group_Code_3_12[0]:
#field[24]: Off#field[25]: Off#field[26]: Off#field[27]:
Off#field[28]: Off#field[29]: Off#field[30]: Off#field[31]:
Off#field[32]: Off#field[33]: Off#field[34]: Off#field[35]:
OffName___Position_1[0]: Name___Position_2[0]:
Other_Firm_Name___Address_1[0]: Other_Firm_Name___Address_2[0]:
Name___Position_1_2[0]: Name___Position_2_2[0]:
Other_Firm_Name___Address_1_2[0]: Other_Firm_Name___Address_2_2[0]:
Name___Position_1_3[0]: Name___Position_2_3[0]:
Other_Firm_Name___Address_1_3[0]: Other_Firm_Name___Address_2_3[0]:
Name___Position_1_4[0]: Name___Position_2_4[0]:
Other_Firm_Name___Address_1_4[0]: Other_Firm_Name___Address_2_4[0]:
Phone_1[0]: Phone_2[0]: Phone_1_2[0]: Phone_2_2[0]: Phone_1_3[0]:
Phone_2_3[0]: Phone_1_4[0]: Phone_2_4[0]: Name___Position_1_5[0]:
Name___Position_2_5[0]: Other_Firm_Name___Address_1_5[0]:
Other_Firm_Name___Address_2_5[0]: Phone_1_5[0]: Phone_2_5[0]:
Page8[0]: Other_Firm_Name[0]: undefined_23[0]:
Other_Firm_Name_1[0]: Other_Firm_Name_2[0]: Other_Firm_Name_1_2[0]:
Other_Firm_Name_2_2[0]: Address_1[0]: Address_2[0]: Address_1_2[0]:
Address_2_2[0]: Address_1_3[0]: Address_2_3[0]: Facility_Type_1[0]:
Facility_Type_2[0]: Owner_or_Name_of_Lessor_andor_rental_agent[0]:
Phone_1_6[0]: Phone_2_6[0]: Phone_1_7[0]: Phone_2_7[0]:
Phone_1_8[0]: Phone_2_8[0]: undefined_24[0]:
Amount_of_yearly_payment_1[0]: Amount_of_yearly_payment_2[0]:
Type_1[0]: Type_2[0]: Type_3[0]: Depreciated___Value_1[0]:
Depreciated___Value_2[0]: Depreciated___Value_3[0]:
Acquisition_Date_1[0]: Acquisition_Date_2[0]:
Acquisition_Date_3[0]: Payment_Terms_1[0]: Payment_Terms_2[0]:
Payment_Terms_3[0]:
Do_any_principles__officers_andor_owners_of_the_firm_have_an_affiliation_ie_business_interest_or_employment[0]:
OffNo_43[0]: OffName_of_Person_1[0]: Name_of_Person_2[0]:
Name_of_Person_3[0]: Firm_Name___Address_1[0]:
Firm_Name___Address_2[0]: Firm_Name___Address_3[0]:
Phone_Number_1[0]: Phone_Number_2[0]: Phone_Number_3[0]:
Nature_of_Business_1[0]: Nature_of_Business_2[0]:
Nature_of_Business_3[0]: Nature_of_Affiliation_1[0]:
Nature_of_Affiliation_2[0]: Nature_of_Affiliation_3[0]:
Page9[0]: Attorney_for_Firm[0]: undefined_25[0]: Address[0]:
Zip_Code_3[0]: undefined_26[0]: State_3[0]:
CPAAccountant_for_Firm[0]: undefined_27[0]: Address_2[0]:
Zip_Code_4[0]: undefined_28[0]: State_4[0]:
Has_the_firm_applied_for_certification_as_an_MWBE_with_another_governmental_agency__department_or_authority[0]:
OffNo_44[0]: Off_1_Pending_With_1[0]: _1_Pending_With_2[0]:
_1_3[0]: _2_3[0]: _1_4[0]: _2_4[0]: _1_5[0]: _2_5[0]: _1_6[0]:
_2_6[0]: _2_Certified_By_1[0]: _2_Certified_By_2[0]: _1_7[0]:
_2_7[0]: _1_8[0]: _2_8[0]: _1_9[0]: _2_9[0]: _1_10[0]: _2_10[0]:
_3_Registered_By_1[0]: _3_Registered_By_2[0]: _1_11[0]: _2_11[0]:
_1_12[0]: _2_12[0]: _1_13[0]: _2_13[0]: _1_14[0]: _2_14[0]:
_1_15[0]: _2_15[0]: _1_16[0]: _2_16[0]: Dollar_Amount_1[0]:
Dollar_Amount_2[0]: Performance_1[0]: Performance_2[0]: _1_17[0]:
_2_17[0]:
Page10[0]: Bank_Name_1[0]: Bank_Name_2[0]: Address_1_4[0]:
Address_2_4[0]: Contact_1[0]: Contact_2[0]: Account_Type_1[0]:
Account_Type_2[0]: Account_Number_1[0]: Account_Number_2[0]:
#field[10]: Off#field[11]: OffSource_1[0]: Source_2[0]: Limit_1[0]:
Limit_2[0]: Name_of_Guarantors_1[0]: Name_of_Guarantors_2[0]:
_1_18[0]: _2_18[0]: CreditLoan_1[0]: CreditLoan_2[0]:
TermsCreditLoans_1[0]: TermsCreditLoans_2[0]: Firm_Name_1[0]:
Firm_Name_2[0]: Address_1_5[0]: Address_2_5[0]: Ownership_1[0]:
Ownership_2[0]: #field[30]: Off#field[31]: Offundefined_29[0]:
Bonding_Company[0]: undefined_30[0]: Phone_Number_1_2[0]:
Phone_Number_2_2[0]: State_5[0]: undefined_31[0]: Zip_Code_5[0]:
Contact_Person[0]:
Page11[0]: pg11_A1[0]: Offpg11_A2[0]: Offpg11_A4[0]:
Offpg11_A3[0]: Offpg11_A8[0]: Offpg11_A7[0]: Offpg11_A6[0]:
Offpg11_A5[0]: Offpg11_A9[0]: Offpg11_A10[0]: Offpg11_A12[0]:
Offpg11_A11[0]: Offpg11_A15[0]: Offpg11_A14[0]: Offpg11_A13[0]:
Offpg11_B1[0]: Offpg11_C2[0]: Offpg11_C1[0]: Offpg11_C3[0]: Off
Page12[0]: Stock_Options[0]: OffShareholder_Agreements[0]:
OffShareholder_voter_rights[0]:
OffRestriction_on_the_disposal_of_stock_loan_agreements[0]:
OffFacts_pertaining_to_the_value_of_shares[0]:
OffBuy-out_rights[0]:
OffRestriction_on_the_control_of_the_corporation[0]: Offpg12_D2[0]:
Offpg12_D1[0]: Offpg12_D6[0]: Offpg12_D5[0]: Offpg12_D4[0]:
Offpg12_D3[0]: Offpg12_E3[0]: Offpg12_E2[0]: Offpg12_E1[0]: Off
Page13[0]: STATE_OF[0]: COUNTY_OF[0]:
the_enterprise_making_the_foregoing_Application_and_that_the_statements_and_representations_made_in_the_Application_are[0]:
Name_of_Corporate_Officer[0]: Title_of_Corporate_Officer[0]:
Name_of_Corporation[0]: Sworn_to_before_me_this[0]: _20[0]:
Notary_Public[0]: Date[0]: Print_Name[0]: Phone_Number[0]:
pg13_20[0]:
