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Civil Rights Bureau

Civil.Rights@iowadot.us

515-239-1422

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Disadvantaged Business Enterprise (DBE)

Program 49 C.F.R. § 26


Uniform Certification Application


Please return this entire document, when completed, to:
Civil Rights Bureau
Iowa Department of Transportation
800 Lincoln Way
Ames, IA 50010
By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.
I am applying for certification as
(10) Is your firm currently certified for any of the following U.S. DOT programs?
(11) (a) Denied certification or decertified as DBE, ACDBE, 8(a), SDB, MBE/WBE firm?
(11)(b) Withdrawn an application for these programs, or debarred or suspended or otherwise had bidding privileges denied or restricted by any state or local agency, or Federal entity?
A. Business Profile: (5) Method of acquisition
A. Business Profile: (6) Is your firm "for profit"?
A. Business Profile: (7) Type of Legal Business Structure
B. Relationships and Dealings with Other Businesses: (1) Is your firm co-located at any of its business locations, or does it share a telephone number, P.O. Box, office or storage space, yard, warehouse, facilities, equipment, inventory, financing, office, staff, and/or employees with any other business, organization, or entity?
B. Relationships and Dealings with Other Businesses: (2) Has any other firm had an ownership interest in your firm at present or at any time in the past?
B. Relationships and Dealings with Other Businesses: (3) At present, or at any time in the past has you firm: (a) Ever existed under different ownership, a different type of ownership, or a different name?
B. Relationships and Dealings with Other Businesses: (3) At present, or at any time in the past, has your firm: (b) Existed as a subsidiary of any other firm?
B. Relationships and Dealings with Other Businesses: (3) At present, or at any time in the past, has your firm: (c) Existed as a partnership in which one or more of the partners are/were other firms?
B. Relationships and Dealings with Other Businesses: (3) At present, or at any time in the past, has your firm: (d) Owned any percentage of any other firm?
B. Relationships and Dealings with Other Businesses: (3) At present, or at any time in the past, has your firm: (e) Had any subsidiaries?
B. Relationships and Dealings with Other Businesses: (3) At present, or at any time in the past, has your firm: (f) Served as a subcontractor with another firm constituting more than 25% of your firm's receipts?
A. Identify the majority owner of the firm holding 51% or more ownership interest: (5) Gender
A. Identify the majority owner of the firm holding 51% or more ownership interest: (6) Ethnic group membership
A. Identify the majority owner of the firm holding 51% or more ownership interest: Describe how you acquired your business
A. Identify the majority owner of the firm holding 51% or more ownership interest: (7) U.S. Citizenship
B. Additional Owner Information (2) Does this owner perform a management or supervisory function for any other business?
B. Additional Owner Information (3)(a) Does this owner own or work for any other firm(s) that has a relationship with this firm?
B. Additional Owner Information (4)(b) Has any trust been created for the benefit of this disadvantaged owner(s)?
B. Additional Owner Information (5) Do any of your immediate family members, managers, or employees own, manage, or are associated with another company?
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm (5) Gender
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm (6) Ethnic group membership
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm: Describe how you acquired your business
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm (7) U.S. Citizenship
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm (2) Does this owner perform a management or supervisory function for any other business?
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm (3)(a) Does this owner own or work for any other firm(s) that has a relationship with this firm?
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm: (4)(b) Has any trust been created for the benefit of this disadvantaged owner(s)?
A. Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm: (5) Do any of your immediate family members, managers, or employees own, manage, or are associated with another company?
Majority Owner- Sets policy for company direction/scope of operations
Minority Owner- Sets policy for company direction/scope of operations
Majority Owner- Bidding and estimating
Minority Owner- Bidding and estimating
Majority Owner- Major purchasing decisions
Minority Owner- Major purchasing decisions
Majority Owner- Marketing and sales
Minority Owner- Marketing and sales
Majority Owner- Supervises field operations
Minority Owner- Supervises field operations
Majority Owners- Attend bid opening and lettings
A. Identify your firm's Officers and Board of Directors (3) Do any of the persons listed above perform a management or supervisory function for any other business?
A. Identify your firm's Officers and Board of Directors (4) Do any of the persons listed in section A above own or work for any other firm(s) that has a relationship with this firm?
Minority Owner- Attend bid opening and lettings
Majority Owner- Perform office management (billing, accounts receivable/payable, etc.)
Minority Owner- Perform office management (billing, accounts receivable/payable, etc.)
Majority Owner- Hires and fires management staff
Minority Owner- Hires and fires management staff
Majority Owner- Hire and fire field staff or crew
Minority Owner- Hire and fire field staff or crew
Minority Owner- Designates profits spending or investment
Majority Owner- Designates profits spending or investment
Majority Owner- Obligates business by contract/credit
Minority Owner- Obligates business by contract/credit
Majority Owner- Purchase equipment
Minority Owner- Purchase equipment
Majority Owner- Signs business checks
Minority Owner- Signs business checks
Officer/Director/Manager/Key Personnel (2) - Sets policy for company direction/scope of operations
Officer/Director/Manager/Key Personnel (1)- Sets policy for company direction/scope of operations
Officer/Director/Manager/Key Personnel (1)- Bidding and estimating
Officer/Director/Manager/Key Personnel (2) - Bidding and estimating
Officer/Director/Manager/Key Personnel (1) - Major purchasing decisions
Officer/Director/Manager/Key Personnel (2) - Major purchasing decisions
Officer/Director/Manager/Key Personnel (1)- Marketing and sales
Officer/Director/Manager/Key Personnel (2) - Marketing and sales
Officer/Director/Manager/Key Personnel (1) - Supervises field operations
Officer/Director/Manager/Key Personnel (2) - Supervises field operations
Officer/Director/Manager/Key Personnel (1) - Attend bid opening and lettings
Officer/Director/Manager/Key Personnel (2) - Attend bid opening and lettings
Officer/Director/Manager/Key Personnel (1) - Perform office management (billing, accounts receivable/payable, etc.)
Officer/Director/Manager/Key Personnel (2) - Perform office management (billing, accounts receivable/payable, etc.)
Officer/Director/Manager/Key Personnel (2) - Hires and fires management staff
Officer/Director/Manager/Key Personnel (1) - Hires and fires management staff
Officer/Director/Manager/Key Personnel (1) - Hire and fire field staff or crew
Officer/Director/Manager/Key Personnel (2) - Hire and fire field staff or crew
Officer/Director/Manager/Key Personnel (1) - Designates profits spending or investment
Officer/Director/Manager/Key Personnel (2) - Designates profits spending or investment
Officer/Director/Manager/Key Personnel (1) - Obligates business by contract/edit
Officer/Director/Manager/Key Personnel (2) - Obligates business by contract/credit
Officer/Director/Manager/Key Personnel (1) - Purchase equipment
Officer/Director/Manager/Key Personnel (2) - Purchase equipment
Officer/Director/Manager/Key Personnel (1) - Signs business checks
Officer/Director/Manager/Key Personnel (2) - Signs business checks
D. Does your firm rely on any other firm for management functions or employee payroll?
B. Does the applicant firm own/operate any off-airport locations?
C. Does the applicant firm currently own/operate any airport concession locations?
D. Does the applicant firm have any affiliates?
E. Is the ACDBE applicant firm a participant in any joint ventures?
I certify that I am a socially and economically disadvantaged individual who is an owner of the above-referenced firm seeking certification as a Disadvantaged Business Enterprise or Airport Concession Disadvantaged Business Enterprise. In support of my application, I certify that I am a member of one or more of the following groups, and that I have held myself out as a member of the group(s)
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