MDHA Diversity Business Enterprise Registration Form Revised 1-12-22

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, woman-owned, small-owned, and service-disabled veteran-owned businesses. We are implementing new initiatives to enhance our current Diversity Business Enterprise (DBE) Program to meet this commitment. (DBE) Program. Our goal is to create more significant procurement opportunities, facilitate partnerships between DBEs and prime contractors, and provide resources to build DBEs' capacity. If you are interested in participating in our program, please complete in its entirety the questionnaire below. The information will ensure that you are listed in our directory of diverse businesses. The directory is utilized by MDHA procurement staff and prime contractors seeking sub-contractors. MDHA will NOT use your information to solicit you for anything other than MDHA procurements of goods and services provided by your company. 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 MDHA IS NOT RESPONSIBLE FOR OUTDATED AND INACCURATE INFORMATION ON A REGISTRATION FORM.
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 Name Last Name
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email: *
Confirm Email *
example@example.com
Website:
Phone Number: *
Industry Classification *
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.
Products/Services *
IMPORTANT Describe in detail the "Products and 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.
Type of Business (Legal Structure): *
Please Select
Year Business Established Under Current Name: *

Month Day Year
Annual Sales Volume: *
Annual Sales Dollars
Total Office Employees: *
Total Warehouse Employees: *
Total Field Employees: *
SECTION IV BUSINESS LICENSE

Please provide information on your company's required license(s)
Type of License(s): *
License Number:
Provide License Number if Applicable
Provide "Other" Type of License:
List "Other" License(s)
'Other ' License Number:
Provide "Other" License Number(s)
SECTION V. INSURANCE INFORMATION

Please provide information on your company's insurance coverage
Company Insurance Coverage :
Company Insurance Coverage: Please indicate YES or NO from the above drop-down menu
Insurance Company Name/Address:
Agent's Name/Telephone Number:
General Liability Insurance:
Insurance Limits
Professional Liability Insurance:
Insurance Limits
Workman Comp Insurance:
Insurance Limits
Insurance Expiration Date:

Month Day Year
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
Bonding Required:
Bonding Company Information:
If not required indicate: N/A
Name of Bonding Agent:
If not required indicate: N/A
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 Preformed, Date, Dollar Amount *
Past Experience: List Contracts/Purchase Orders Performed
PAST CONTRACTS/PURCHASE ORDER: Client Name, Work Performed, Date, Dollar Amount
Past Experience: List Contracts/Purchase Orders Performed
PAST CONTRACTS/PURCHASE ORDER: Client Name, Work Performed, Date, Dollar Amount
Past Experience: List Contracts/Purchase Orders Performed
SECTION VIII. DIVERSITY BUSINESS ENTERPRISE CERTIFICATION

NOTE: MDHA only recognizes the agencies listed in the below drop-down menu
Diversity Business Enterprise Classification: *
Select DBE Classification
Certification Agency and/or Small Business Approval Agency: *
Upload a copy of your MBE/WBE/SDVBE Certification or BAO Small Business Approval Letter. 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.

MBE/WBE/SDVBE Certification or Small Business Approval Letter
Cancel of
Certification Expiration Date:

Month Day Year
IF NOT CERTIFIED, please provide a statement below of your intent to become certified. FOR QUESTIONS REGARDING CERTIFICATION or ASSISTANCE WITH GETTING CERTIFIED PLEASE EMAIL: DBEinquiries@Nashville-MDHA.org
SECTION IX. OWNERSHIP INFORMATION

IMPORTANT: Provide the information below on the "Majority Business Owner"
Majority Business Owner: *

First Name Last Name
Ethnic Classification: *
Select Ethnicity
Gender: *
Select Gender
% of Ownership : *
% of Ownership
"Other" Owners
If "Yes" list "Other Owners" below
List Other Owners Information *
Provide name(s) ethnicy, gender and % of Ownership for each individual listed
SECTION X. SIGNATURE
The undersigned hereby declares that all information provided on this Diversity Business Enterprise Program Registration Form by the business owner(s) and all attachments provided are genuine, accurate, and complete and will be accepted as statements of fact. The typed signature below will be considered as your official signature for this DBE Program Registration. *
Signature
SUBMITTING THE FORM: To complete the form, you must click the save button prior to clicking the submit button. After you click the save button you will be prompted to review the form to make sure that you did not omit any required information. After review click the submit button.

IMPORTANT: YOU ARE REQUIRED TO KEEP YOUR INFORMATION UPDATED AFTER REGISTRATION. FOR QUESTIONS REGARDING REGISTRATION PLEASE EMAIL: YOLANDA FLAKES: yflakes@nashville-mdha.org or via telephone at 615-252-6734

FOR QUESTIONS REGARDING CERTIFICATION or ASSISTANCE WITH GETTING CERTIFIED PLEASE EMAIL: DBEinquiries@Nashville-MDHA.org

PLEASE SAVE THE FORM TO COMPLETE AT A LATER DATE OR TO MAKE REVISIONS

Donot forget to register in the Housing Agency Marketplace so that you can receive timely information on MDHA upcoming procurements for goods and services.
Should be Empty:

METROPOLITAN DEVELOPMENT AND HOUSING AGENCY

Diversity Business Enterprise Program Registration

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. OWNERSHIP INFORMATION

SECTION X. SIGNATURE