CERTIFICATION APPLICATION

BROWARD

COUNTY

PUBLIC

SCHOOLS

Minority Business Enterprise

Women Business Enterprise

CERTIFICATION APPLICATION

Supplier Diversity & Outreach Program

7720 W Oakland Park Boulevard, Suite 323

Sunrise, FL 33351

Phone: 754-321-0550

BROWARD COUNTY PUBLIC SCHOOLS

CERTIFICATION APPLICATION

General Guidelines

CERTIFICATION:

Minority Business Enterprise (MBE) Certification

A Minority Business Enterprise (MBE) means one which is at least fifty-one percent (51%) owned and controlled by minority group member(s). Minority group members are:

 African American (Black Americans), a person having origins in any of the Black racial groups of Africa.

 Native American which includes persons who are American Indians, Eskimos, Aleuts, or Native Hawaiians.

 Asian-Pacific American, which includes persons whose origins are from Japan, China, Taiwan, Korea, Burma (Myanmar), Vietnam, Laos, Cambodia (Kampuchea), Thailand, Malaysia, Indonesia, the Philippines, Brunei, Samoa, Guam, the U.S. Trust Territories of the Pacific Islands (Republic of Palau), the Commonwealth of the Northern Marianas Islands, Macao, Fiji, Tonga, Kirbati, Javalu, Nauru, Federated States of Micronesia, or Hong Kong.  Subcontinent Asian-American, which includes persons whose origins are from India,

Pakistan, Bangladesh, Bhutan, the Maldives Islands, Nepal or Sri Lanka.

 Hispanic American, a person of Spanish or Portuguese culture which includes persons of Mexican, Puerto Rican, Cuban, Dominican, Central or South American, or other Spanish or Portuguese culture or origin regardless of race.

(Source 49CFR 26, 10-1-04)

Women-owned Business Enterprise (WBE) Certification

A Woman-Owned Business Enterprise (WBE) means one that is at least fifty-one percent (51%) owned and controlled by Caucasian females.

BROWARD COUNTY PUBLIC SCHOOLS

INSTRUCTIONS FOR COMPLETING CERTIFICATION APPLICATION

SECTION I – GENERAL APPLICANT INFORMATION

A. Write in the name of the person(s) who have an ownership interest in the business. The telephone number and business address should be for your main office. Be sure to include area codes for all phone and fax numbers. If your company has a federal Employer Identification Number (EIN), please provide the number. If not, please provide the social security number listed on the firm’s tax return. B. Check the ethnicity and gender for which your firm is seeking certification.

C. Circle US Citizenship or Permanent Resident Status.

D. Check the type of business structure of your firm and the datestartedoracquired. E. Firm’s whose primary operation is home based.

F. Provide the name(s) and addres(es) of all branch offices, subsidiaries, and/or affiliates of the firm for which certification is being sought.

G. Refer to the NAICS (North American Industry Standards) Code listing and provide the code(s) that best describes the service, product, or work of the firm. NAICS listings can be found on the internet at

www.sba.gov/size or at your local library.

H. Write a brief description of your firm’s primary products, services, or work areas. This is how your firm will be described in the Certification Directory should you be granted certification.

SECTION II – OWNERSHIP

A. List the name of all owner(s) with ethnicity and gender and percentage of ownership. List all contributions of cash, equipment, etc. made by all of the owners including those at the time the firm was started or acquired.

B. Indicate if the ownership interest of any of the owners has changed since the business was started or acquired.

C. List any additional capital contributions of cash, equipment, etc. made by anyone other than owner(s) listed in Section II (A).

D. If ownership interest was acquired by gift, transfer, or inheritance/divorce, please provide requested information.

E. Give a written explanation of any stipulations/conditions attached to the assets noted in Section II (D). F. Provide information regarding any stock that has been authorized and/or issued by the company. Refer

to Articles of Incorporation.

G. Are the voting rights of any shareholder limited in any way? If so, provide information/documentation regarding the nature of the restriction.

H. List the name, ethnicity, and title of each person who is a member of the Board of Directors for the company. If the firm is a sole proprietorship or partnership, please indicate Not Applicable (N/A).

SECTION III – FINANCIAL INFORMATION

A. Provide the name(s) of the banks, credit unions, etc. where you have business accounts and identify the type of account(s) in each institution.

B. List the gross earnings of the company for the most recent three (3) years. This amount should match the gross earnings listed on the business tax return for the firm.

C. Provide bonding information, if applicable.

SECTION IV - CONTROL

A. Provide information for those individuals in the firm that make decisions for the areas listed. B. List the salaries or other compensation received by the owners and/or officers of the firm.

C. 1. If anyone in authority in the business holds stock in another firm engaged in the same, or similar business, respond YES to this question.

2. If anyone in authority in the business is a former owner, current owner, or works for another firm engaged in the same or similar type of business as this firm, respond YES to this question.

3. If you answered YES to questions 1 and/or 2 above, please provide the name of the person(s), ethnicity and gender, name of the other company, the ownership percentage owned by the individual(s), and/or the position held in the other company.

D. Business relationships include: common ownership, management/employees, office space and contractual relationships with other firms.

E. Explain any changes of the firm’s Board of Directors and officers within the last two (2) years. F. Provide current number of employees, full and part-time.

SECTION V – OTHER CERTIFICATION

A. If the business is currently certified as a MBE, WBE, SBE, and/or DBE with another agency anywhere in the United States, please provide the name of the agency, the type of certification, and the date the certification will expire.

B. If a certification site visit was conducted prior to granting certification approval, please indicate.

C. If the firm or any of its owners, directors, officers applied or been denied MBE, WBE, SBE, and/or DBE certification, please indicate.

CERTIFICATION AFFIDAVIT – MUST BE COMPLETED BY ALL APPLICANTS

The Affidavit must be signed by the minority/woman owner(s) of the firm. The affidavit must be notarized. False statements will subject the firm to decertification and/or denial of future certification.

SUPPORTING DOCUMENT CHECKLIST

All applicants MUST forward the required documents listed on the checklist with the completed certification application.

NOTE: Failure to follow these instructions may delay the processing of the application. All questions must be completed and requested documents submitted. The affidavit must be signed and notarized, accordingly. Questions that do not apply to your firm should be marked “N/A” in the space provided. Mail this application to only one certifying agency, listed on back page.

BROWARD COUNTY PUBLIC SCHOOLS

MBE / WBE

CERTIFICATION APPLICATION

Please Read Instructions Carefully – Completed Application Must be Signed & Notarized

From the following four options, please check which form(s) of certification you are requesting. You may request certification in more than one category.

Minority Business Enterprise (MBE) Complete Sections I-V & Affidavit Woman-Owned Business Enterprise (WBE) Complete Sections I-V & Affidavit

SECTION I - GENERAL APPLICANT INFORMATION

E. Is this a home based business? YES NO

F. List all branch offices/subsidiaries/affiliates:

Name Address

A. Applicant (s) Name________________________________________________________________________ Legal Name of Firm________________________________________________________________________ Other Names Used by Firm (DBA)_____________________________________________________________ Street Address of Firm ______________________________________________________________________ City _________________________________________ State _____________ Zip Code _________________ Mailing Address (if Different from Street Address) _________________________________________________ Telephone Number ( __ )______________________ Fax Number ( __ )__________________________

Email: _______________________________ Website:_____________________________________ Firm’s Federal EIN or Owner’s Social Security Number:___________________________________________ B. Ethnicity/Race: African American Asian Pacific-American Hispanic American Native American

White Subcontinent Asian-American Other Gender: Male Female

C. Is (are) principal owner(s) of the company a United States Citizen(s)? Y N If no, is the Owner a Permanent Resident? Y N

D. Type of Firm : Sole Proprietorship Partnership Corporation Tribal Enterprise Limited Liability Corp. Limited Liability Partnership

G. List all NAICS Codes that apply to your firm (for an up-to-date list, visit www.sba.gov/size on the internet): { } { } { } { } { } { }

H. Please provide a brief description of the primary area(s) of work performed in the business. This is how your firm will be listed and described in the certification directory. (Attach extra page if necessary)

SECTION II – OWNERSHIP

A. List all contributions/investments of cash, equipment, real estate, expertise, or other considerations used to acquire ownership for each owner(s).

Name of Owner:_______________________________ Name of Owner:_________________________________ Ethnicity & Gender:_____________________________ Ethnicity & Gender_______________________________ % of Stock Ownership:__________________________ % of Stock Ownership:____________________________ Cash: _______________________________ Cash: _________________________________ Equipment: _______________________________ Equipment: _________________________________ Real Estate: _______________________________ Real Estate: _________________________________ Other: _______________________________ Other: __________________________________ TOTAL: _______________________________ TOTAL: __________________________________

Name of Owner:_______________________________ Name of Owner:_________________________________ Ethnicity & Gender:_____________________________ Ethnicity & Gender_______________________________ % of Stock Ownership:__________________________ % of Stock Ownership:____________________________ Cash: _______________________________ Cash: _________________________________ Equipment: _______________________________ Equipment: _________________________________ Real Estate: _______________________________ Real Estate: _________________________________ Other: _______________________________ Other: _______ __________________________ TOTAL: _______________________________ TOTAL: _______ __________________________

B. Has this ownership percentage changed since the firm was started or acquired? YES NO If a change has occurred, when did the change occur? ______/_________/________

If a change has occurred, please explain the details of the change below:

C. List any additional contributions made by anyone since the business started or acquired.

Name of Contributor Type of Contribution Value of Contribution

D. List any assets used to acquire ownership or make additional contributions that were received as a gift, transfer of shares or inheritance/divorce.

Asset Type Value Contributor

E. Explain any stipulations/conditions attached to the gift, transfer or inheritance/divorce, listed above.

F. Has your firm authorized and/or issued shares of stock? YES NO If yes, please answer the following questions:

1. Number of Shares Authorized: ____________ ____________ _______ (See Articles of Incorporation) Preferred Common Other

2. Number of Shares Issued: _____________ _____________ ________ Preferred Common Other

G. Do restrictions exist within the by-laws, Articles of Incorporation, or other document(s) that limit the voting rights of any shareholder? YES NO If Yes, please explain:

H. List Board Members/Directors and their title(s) (if applicable).

SECTION III - FINANCIAL INFORMATION

A. List the name of the financial institution(s) where you have business accounts. Identify type of account; i.e., checking, line of credit, loan, savings, etc.

Name Type of Account

B. List the firm’s gross receipts for each of the last three years (or life of firm if less than 3 years). Year Gross Receipts

C. Provide the name and contact number of your bonding agent and the firm’s current bonding capacity. (If applicable) Bonding Agent Current Bonding Capacity

D. List the three largest contracts or sales completed by the firm during the last three years. List each Customer’s name and company or organization, the dollar amount of each contract or sales, and the date completed. If any are subcontracts indicate the contract as such and provide the name of the firm to which you subcontracted.

1) Customer Name: Company or Organization: Contract Amount: $ Date: 2) Customer Name: Company or Organization: Contract Amount: $ 3) Customer Name: Company or Organization: Contract Amount: $

SECTION IV - CONTROL

A. Responsibilities – List the name(s) of individual(s) responsible for the following decisions:

Decisions Name of Person Title Ethnicity/Gender Financial

Office Management

Estimating/Bidding

Marketing/Sales Hiring/Firing Mgmt. Personnel

Hiring/Firing Field Personnel Purchasing – Major

Negotiating Bonds/Loans Supervision of Field Operations Signing for Payroll/Insurance Negotiating Contracts Signing Contracts Signing Checks

B. Indicate the annual salaries of all officers, owners and those individuals responsible for the day-to-day operations of the firm. Where no salary is drawn, please indicate the method of compensation.

Name Title Salary/Compensation

C. 1. Does any owner, board of director or officer own stock in another firm engaged in a similar type of business? YES NO

2. Is any owner, board of director or officer a current employee, owner, or former owner of any firm engaged in the same or similar type of business? YES NO

3. If you answered yes to either of the above questions, please list the individual’s name, ethnicity and gender, name of the other company, ownership percentage, and position held with the other firm.

D. Is this business an affiliate of any other business? YES NO

(Businesses are affiliates of each other when they share common ownership, common management, or any contractual relations).

If yes, please provide detailed information for the following common areas: Ownership:

Management/Employees: Office Space:

Contractual Relationships:

E. Explain any changes in the duties and/or powers attributable to any owner, principal, officer, or director of the firm during the past two (2) years.

F. Current number of Employees: _________________

Full Time __________ Part Time __________

SECTION V - OTHER CERTIFICATIONS

A. Is this business currently certified as a Minority, Woman, Disadvantaged, and/or Small Business Enterprise by any local, state, or federal agency? YES NO If yes, please list the name of the agency and the date the current certification will expire.

Agency Type of Certification Expiration Date

B. Was a site visit conducted as part of the above certification process? YES NO

C. Has this firm or any of its owners, members of the Board of Directors, officers, or management personnel ever been denied certification/recertification or been decertified, suspended, or debarred as a MBE, WBE, DBE and/or SBE? YES NO

If yes, please explain:

Section VI – Broward County Small Business Enterprise ONLY

The Small Business Program affords Broward County small businesses the opportunity to participate in the County’s sheltered market program for projects under $250,000. Answer these questions if you would like to be considered for

SBE certification.

A. How many permanent full time employees does your firm employ? ________ B. Type of business activity – check one:

____ Construction Services

____ Contract Services ____ Commodities Supplier

____ Licensed professional services

I hereby authorize the Broward County Small Business Development Division to verify the accuracy of the statements made in this application in order to determine whether I meet the standards established for the Broward County Small Business Certification Program. These statements are true and correct to the best of my knowledge.

_________________________________ ______________________________________ _____/_______/_______ Signature of Applicant Title Date

FOR OFFICIAL USE ONLY Originating Agency:

Processed Date:

Approved By/Title:

BROWARD COUNTY PUBLIC SCHOOLS

MBE / WBE

CERTIFICATION APPLICATION AFFIDAVIT

I hereby swear that I have the authority to sign this affidavit as the Minority, Woman-Owned, and/or Small Business Enterprise owner of the Applicant Firm noted below. I further swear that the statements on the accompanying Certification Application form and all accompanying documents are true, complete, and correct and include all materials necessary to explain the ownership and operation of the applicant firm. I affirm that any changes that have occurred during the past twelve months in the ownership, control, structure, or operation of the firm have been fully disclosed herein by attachment or notation.

_______________________________________________________________ (Name of Applicant Firm)

The above named firm agrees:

1. To abide by the requirements of the MINORITY-OWNED BUSINESS ENTERPRISE (MBE), WOMAN-OWNED BUSINESS ENTERPRISE (WBE), and/or SMALL BUSINESS ENTERPRISE (SBE) as indicated on this application, and all of the applicable rules/regulations/policy guidelines of any/all of the entities for which this application is applicable.

2. To notify all entities with whom the applicant is seeking certification through this application within ten (10) working days of any change in the ownership, control, management, or status of the firm. To also, notify the same entities of any denial or decertification of this firm as a MBE, WBE, DBE, and/or SBE by any other certifying agency.

3. That, in order to monitor the status of the firm, all entities with whom the applicant is seeking certification through this application has the right, from time to time, to review the firm’s books, contracts, facilities, and records. Entities also may request and review any additional information deemed necessary to complete such process.

4. That failure to answer any question or to supply to the applicable entities with any documentation requested during the application process may be cause to deny the certification request.

5. That all entities with which the applicant is seeking certification through this application, for cause, may withdraw certification after applying its own approved procedures.

6. That all entities with which the applicant is seeking certification through this application may deny certification or rescind certification and initiate action under Federal or State laws concerning false statements. This may occur, if during or after the certification process, it is found that the undersigned have submitted false, inaccurate, or misleading information.

7. That all of the entities with whom the applicant is seeking certification through this application have the right to refuse certification of any firm, based on its implementation of the MBE, WBE, and/or SBE eligibility standards, despite the fact that the firm may be certified by another entity.

8. Any information contained in this application, or obtained during on-site reviews, may be released to other certifying agencies with which the applicant has applied for certification.

companies, banking institutions, credit agencies, contractors, clients, and other certifying agencies for the purpose of verifying the information supplied and determining the named firm’s eligibility.

10. That the undersigned will provide, either directly to the certifying entity or through a prime contractor, current, complete, and accurate information regarding actual work performed as a MBE, WBE, DBE, and/or SBE on a contract. The applicant further agrees to supply documentation regarding payments for work performed, any proposed change to the arrangements on the contract, and to permit the audit and examination of books, records, and files of the named firm. Any material misrepresentation will be grounds for terminating any contract that may be awarded and for initiating action under local, Federal, or State laws concerning false statements.

By my signature I recognize and accept the preceding statements governing the consideration of this MBE, WBE, and/or SBE application.

Printed name of Owner: __________________________________________________

Owner’s Signature: _____________________________________________________

NOTARY:

On this ___________ day of ____________________________, ___________, the above named person did appear before me and being duly sworn, did execute the foregoing Affidavit and did state that he or she was properly authorized by:

(Name of Firm) _________________________________________________ to execute the Affidavit and did so of his/her own free act and deed.

In witness whereof, I have hereunto set my hand and official seal.

Personally Know OR Produced I.D._______________________ State of:___ _____________________________________ County of:_______________________________________ Notary Signature:_________________________________

BROWARD COUNTY PUBLIC SCHOOLS

MBE / WBE

CERTIFICATION APPLICATION

SUPPORTING DOCUMENTS CHECKLIST

Two pieces of documentation showing proof of ethnicity and/or gender of the minority/woman owner(s): (One document must be a photo ID) i.e. driver’s license, birth certificate, passport tribal registration, etc.

Copies of all occupational licenses

Copies of all professional licenses

Copy of minority/woman owner(s) resume

Owners who are not U.S. citizens must submit proof of legal permanent residence.

PLEASE SUBMIT FOR THE SCHOOL DISTRICT’S MBE/WBE CERTIFICATION ONLY:

Copies of Federal Corporate Tax returns (pages 1-4) and Schedule K-1 or Schedule E for the last three fiscal years.

(past 3 years) –

Signature Card(s) or letter from bank verifying signatures and number of signatures required.

Quarterly Wage Report UCT-6 – all employees (Four (4) quarters Bylaws, with amendments

FOR CORPORATION and LLC:

Official Articles of Incorporation (signed by the state official)

Both sides of all corporate stock certificates and your firm’s stock transfer ledger

Official Certificate of Formation and Operating/Management Agreement with any amendments (for LLCs)

Copies of corporate by-laws with amendments and all resolutions affecting ownership.

FOR SOLE PROPRIETORSHIP:

Official Filing Documents with State Agency – (Fictitious Name)

FOR PARTNERSHIP OR JOINT VENTURE:

BROWARD COUNTY PUBLIC SCHOOLS

MBE / WBE

F

or M/WBE Certification mail to this agency:



Keith Roberts, MWBE Specialist Marcy Houser, MWBE Specialist

Phone-(754) 321-0550 Fax-(754) 321-0934 E-mail: [email protected]

http://www.broward.k12.fl.us/supply/MWBE.htm

For information on Broward County Government SBE and CBDE programs:



115 S. Andrews Avenue, Annex A-640 Fort Lauderdale, FL 33301

Small Business Development Manager Phone-(954) 357-6400 Fax-(954) 357-6742 E-mail: [email protected]

Non-certifying agencies:

These agencies accept Broward County Public Schools MBE/WBE Certification.

Broward Community College 225 East Los Olas Boulevard Fort Lauderdale, Florida 33301 Shirley Gainey-Dollar

Phone-(954) 201-7307 Fax-(954) 201-7330 E-mail: [email protected]

Memorial Healthcare System Services 2900 corporate Way, Doorway C Miramar, Florida 33025-3925

Dana Hightower, Vendor Relations Coordinator Phone-(954) 276-5496

Fax-(954) 985-3497

E-mail: [email protected]

City of Hollywood City of Fort Lauderdale Local MBE and SBE Program 100 N. Andrews Avenue

2600 Hollywood Blvd., Suite 422 Fort Lauderdale, Florida 33301 Hollywood, Florida 33022-9045 Bobbi Williams

Arline Hampton Phone (954) 828-5142 Fax (954) 828-5576 Phone (954) 921-3388 Fax (954) 921-3497 E-mail: [email protected]

E-mail: [email protected]

North Broward Hospital District Office of Supplier Diversity 303 SE 17th Street, Suite 308 Fort Lauderdale, Florida 33316 LaRae Floyd

Phone (954) 831-2794 Fax (954) 831-2790 E-mail: [email protected]