MDHA Diversity Business Enterprise Registration Form Revised 1-30-24

METROPOLITAN DEVELOPMENT AND HOUSING AGENCY
DIVERSITY BUSINESS ENTERPRISE PROGRAM REGISTRATION

Metropolitan Development and Housing Agency (MDHA) is committed to developing valuable relationships with minority-owned (MBE), woman-owned (WBE), small-owned (SBE), and service-disabled veteran-owned businesses (SDVBE). Collectively we refer to these businesses as Diversity Business Enterprise (DBE) Our goal is to create more significant procurement opportunities, facilitate partnerships between DBEs and prime contractors, and provide resources to help build DBEs' capacity. The information you provide will ensure you are listed correctly in our directory of diverse businesses. The DBE Directory is utilized by MDHA procurement staff when soliciting goods and services. Prime contractors also use the directory when seeking DBE subcontractors and suppliers of various goods and services. MDHA will NOT use your information to solicit you for anything other than MDHA procurements of goods and services provided by your company.
DIVERSITY BUSINESS ENTERPRISE SELF-REPRESENTATION

MDHA offers a "Self-Representation Approval" for businesses that meet the definition of a minority-owned, women-owned, small-owned, and service-disabled veteran-owned business enterprise. Businesses that identify as one of these classifications must be able to provide information that will substantiate their claim, such as ethnicity, gender, ownership, management, and control. To apply for MDHA Self-Representation Approval, complete Section IX "Business Ownership and Control Information." After a review of your information to determine if your business meets the classification of DBE, you will receive an email with a notification of your Self-Representation Approval. If the information you provide is insufficient, you will receive an email to provide further information. NOTE: MDHA Self-Representation Approval ONLY pertains to MDHA. The Self-Representation Approval is not accepted by other city, state or federal DBE program.
INSTRUCTIONS FOR COMPLETING THIS FORM

INSTRUCTIONS: After completing the registration form, click the “REVIEW” button to ensure you have completed each section. After reviewing, click the “Save” button to save the document for future editing. After you have saved the form, click the “SUBMIT’ button to submit the form. After submitting the form, you should receive an email confirming your registration submission. FOR QUESTIONS OR ISSUES COMPLETING THIS FORM CONTACT: gdavis@simsdiversityconsult.com
SECTION I. GENERAL BUSINESS INFORMATION
Legal Business Name as Registered with the State of Tennessee (if applicable)*
Legal Business Name
Name of Legal Business Owner*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email:*
Confirm Email*
example@example.com
Website
Phone Number*
SECTION II. PRODUCTS/SERVICES PROVIDED

IMPORTANT: Please provide clarity in this section on the products and services provided by your company. Clarity of your products and services will help MDHA identify your company for upcoming procurement opportunities. Please do not use codes numbers. Use the boxes below to enter the products and/or services provided by your company.
Industry Classification*
Products/Services*
IMPORTANT Provide a brief description of the "Products and/or Services" your company provides: *
SECTION III. BUSINESS STRUCTURE

IMPORTANT: Accurate information provided herein will help MDHA in its efforts to identify procurement opportunities for DBEs, facilitate partnerships between DBEs and prime contractors, and provide resources that can assist in building the capacity of DBEs.
Business (Legal Structure)*
Please Select
Year Business Established*
Employer's Identification Number*
If not applicable indicate N/A
Annual Sales Volume*
Example: $500,000.00
Number of Employees*
Number of Contract Workers*
If you do not use contract workers Indicate N/A
SECTION IV BUSINESS LICENSE

Please provide information on your company's required license(s)
Type of License(s) Applicable to Business Industry *
"Other" Type of License:*
List "Other" License(s) If not applicable, indicate N/A
SECTION V. INSURANCE INFORMATION

Please provide information on your company's insurance coverage
Company Insurance Coverage *
Please indicate YES or NO from the above drop-down menu
Commercial General Liability*
If not applicable indicate N/A
Automobile Liability *
If not applicable indicate N/A
Professional Liability *
If not applicable indicate N/A
Umbrella Liability*
If not applicable indicate N/A
Workman Comp *
If not applicable indicate N/A
SECTION VI. BONDING INFORMATION

Please provide information on your company's current " Bonding" status. If not required for the type of products and services you provide, indicate N/A
Is Bonding Required for your Business Industry?*
Please indicate YES or NO from the above drop-down menu
Describe Bonding Coverage *
If not required indicate: N/A
SECTION VII. COMPANY EXPERIENCE

List two or three largest Contract(s) and/or Purchase Order(s) performed by your company
PAST CONTRACTS/PURCHASE ORDERS: Client Name, Work Performed, Date, Dollar Amount *
SECTION VIII. DIVERSITY BUSINESS ENTERPRISE CERTIFICATION

NOTE: MDHA only recognizes the certification agencies listed in the below drop-down menu
Diversity Business Enterprise Certification Classification:*
Select DBE Classification
Certification Agency and/or Small Business Approval Agency:*
EXPIRATION DATE: Provide your Certification or SBE Approval Expiration Date: *
If not applicable Indicate N/A
If NOT Certified, please indicate if you are interested in receiving Technical Assistance with the certification process.*
If NOT Certified, please indicate if you have provided this information to Self-Identify your company as one of the following: MBE, WBE, SBE or SDVBE*
Upload a copy of your MBE/WBE/SBE/SDVBE Certification, or BAO Small Business Approval Letter and other requested documents here:

IMPORTANT: Please keep your certification information updated to remain on the DBE Program Directory. IF NOT CERTIFIED, please see the box below to provide a statement of your intent to become certified.
Cancelof
SECTION IX. BUSINESS OWNERSHIP and CONTROL INFORMATION

IMPORTANT: You must provide information for each owner, regardless of whether each owner’s status is a minority, woman, small, or service-disabled veteran. If you are not certified, please upload any information that will assist MDHA in determining that as the majority owner, you own, operate, and control the business and are a U.S. Citizen.
Majority Business Owner:*

First Name Last Name
Ethnic Classification: *
Select Ethnicity
Gender:*
Select Gender
% of Ownership:*
% of Ownership
Are you a US citizen?*
1. "Other" Business Owner:

First Name Last Name
Ethnic Classification:
Select Ethnicity
Gender:
Select Gender
% of Ownership:
% of Ownership
Are you a US citizen?
2. "Other" Business Owner:

First Name Last Name
Ethnic Classification:
Select Ethnicity
Gender:
Select Gender
% of Ownership:
% of Ownership
Are you a US citizen?
SECTION X. SIGNATURE
IMPORTANT: IT IS ESSENTIAL TO KEEP INFORMATION ON YOUR REGISTRATION CURRENT AND ACCURATE. MDHA IS NOT RESPONSIBLE FOR OUTDATED AND INACCURATE INFORMATION ON A REGISTRATION FORM.
I confirm that the statements, representations, and information on this form is true and correct. I agree to provide MDHA with any information and materials that MDHA may need to substantiate my business claim as a DBE. This may include cooperation with MDHA to examine books, records, and business files. I understand that any material misrepresentation may be grounds for voiding my DBE registration, DBE Self-Representation Approval or for terminating any contract that might be awarded and for imposing sanctions under federal, state, or local laws concerning false statements. If MDHA includes my business in its DBE Directory and any information provided in this form changes during the ensuing year, I will inform MDHA promptly by updating my information. The typed signature below will be considered your official signature for this DBE Program Registration and DBE Self-Representation Process.*
Signature
Review this form before submitting it. You cannot submit the form until you click the review button. FOR QUESTIONS OR ISSUES COMPLETING THIS FORM CONTACT: gdavis@simsdiversityconsult.com
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METROPOLITAN DEVELOPMENT AND HOUSING AGENCY

DIVERSITY BUSINESS ENTERPRISE PROGRAM REGISTRATION

DIVERSITY BUSINESS ENTERPRISE SELF-REPRESENTATION

INSTRUCTIONS FOR COMPLETING THIS FORM

SECTION I. GENERAL BUSINESS INFORMATION

SECTION II. PRODUCTS/SERVICES PROVIDED

SECTION III. BUSINESS STRUCTURE

SECTION IV BUSINESS LICENSE

SECTION V. INSURANCE INFORMATION

SECTION VI. BONDING INFORMATION

SECTION VII. COMPANY EXPERIENCE

SECTION VIII. DIVERSITY BUSINESS ENTERPRISE CERTIFICATION

SECTION IX. BUSINESS OWNERSHIP and CONTROL INFORMATION

SECTION X. SIGNATURE