Government Certification Information Form
Contact Person
First Name
Last Name
Title
Legal Business Name
Federal Tax ID (if your business is for profit)
Phone Number
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
E-mail
Street Address of Business
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Mailing Address of Business (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Business
Please Select
Sole Proprietorship
Limited Liability Partnership
Partnership
Corporation
Limited Liability Company
Joint Venture
ACDBE
Other, please specify below.
Others
Are you an active U.S. military member
Yes
No
Is your spouse an active U.S. military member, if applicable
Yes
No
Time Zone
Pacific Time
Mountain Time
Central Time
Eastern Time
Is your business currently certified in any other government programs? Please list
Concise description of the businesses primary activities and the products or services it provides
Total number of employees (full-time, part-time, and seasonal)
Provide a list (employee, job title, & dates of employment)
Back
Next
Specify the businesses gross receipts for last 3 years (provide complete copies of the firm's Federal tax returns)
Year
Gross Receipts of Application Firm
Gross Receipts of Affiliate Firm
1
2
3
Does your business share a telephone, P.O. Box, office/storage space, yard, warehouse, facilities, equipment inventory, financing, office space, and/or employees with any other business entity?
Yes
No
Date business was established
-
Month
-
Day
Year
Date
Method of acquisition
Started new business
Bought existing business
Inherited business
Secured concession
Merger or consolidation
Other. please explain below
Other
Bank Name
Bank Account Number
Branch Name and Routing Number
Firm's parent name (if applicable)
Business license number
Issuing City & State
DeKalb County employee current or past?
Yes
No
If Yes, list employee name and dates of employment
Organizations 1099 category
Attorney
Medical Facility or Physician
Not Applicable
Other Non-Employee Compensation
Primary business classification
Court Supplier
Distributor
Freight Carrier
Government Agency
Manufacturer
Non-Profit
Professional Association
Service Provider
Professional License city, county, or state
Professional Licensing issuing city, county, or state
If professional license is not required, please provide city, county, or state
Are you submitting a W9 form?
Yes
No
Are you submitting a Conflict of Interest form (must have the completed form attached)
Yes
No
Identify the majority owner of the business
51% or more ownership
Name
First Name
Last Name
Title
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of years as owner?
Gender
Male
Female
Percent owned
Date aquired
-
Month
-
Day
Year
Date
U.S. Citizenship
U.S. Citizen
Lawfully Admitted Permanent Resident
Ethnic Group
African-American (non-Hispanic)
Asian Pacific
Hispanic
Native American
Subcontinent Asian
Other
Method of acquisition
Started new business
Bought existing business
Inherited business
Secured concession
Merger or consolidation
Other. please explain below
Additional Owner Information
Describe familial realtionship to other owners if there are any.
Does this owner perform a management or supervisory function for any other business? If Yes, identify business name and title)
Does this owner own or work for any other firm(s) that has a relationship with this business? (ownership interest, shared office space, financial investments, etc.)
Yes
No
Identify the business name, nature of the relationship, and the owner's function at the firm.
Does the owner work for any other firm or engaged in any other activity more than 10 hours a week?
Yes
No
If Yes, identify this activity
What is the personal net worth of this disadvantaged owner applying for certification?
Has any trust been created for the benefit of this disadvantaged owner(s)?
Yes
No
Do any of your immediate family, managers, or employees own, manage or are associated with another company?
Yes
No
If Yes, provide their name, relationship, company, type of business, and indicate whether they own or manage the company.
Identify all individuals, firms, or holding companies that hold LESS THAN 51% ownership interest in the firm (attach separate sheets for each additional owner)
Name
First Name
Last Name
Title
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Ethnic Group
African-American (non-Hispanic)
Asian Pacific
Hispanic
Native American
Subcontinent Asian
Other
U.S. Citizenship
U.S. Citizen
Lawfully Admitted Permanent Resident
Number of years as owner?
Percent owned
Initial investment to acquire ownership interest in firm
Dollar Value
Cash
Real Estate
Equipment
Other
Method of acquisition
Started new business
Bought existing business
Inherited business
Secured concession
Merger or consolidation
Other. please explain below
Other
Describe familial realtionship to other owners if there are any.
Does the owner work for any other firm or engaged in any other activity more than 10 hours a week?
Yes
No
If Yes, identify this activity
What is the personal net worth of this disadvantaged owner applying for certification?
Has any trust been created for the benefit of this disadvantaged owner(s)?
Yes
No
Do any of your immediate family, managers, or employees own, manage or are associated with another company?
Yes
No
If Yes, provide their name, relationship, company, type of business, and indicate whether they own or manage the company.
Do any of the persons listed above perform a management or supervisory function for any other business?
Yes
No
If Yes, identify for each (person, title, business, and function)
Do any of the individuals mentioned above own or work for any other firm(s) that has a relationship with this business? (ownership interest, shared office space, financial investments, etc.)
Yes
No
Identify the business name, nature of the relationship, and the owner's function at the firm.
Back
Next
Inventory
Indicate your firm's inventory in the following categories by attaching the information on additional sheets of paper
Equipment & Vehicles
Make and Model
Current Value
Owned or Leased by Firm or Owner
Used as Collateral
Where is item stored
Office Space
Street Address
Owned or Leased by Firm or Owner
Current Value of Property or Lease
Storage Space
Street Address
Owned or Leased by Firm or Owner
Current Value of Property or Lease
If you have bonding capacity, identify the firm's bonding aggregate and project limits.
Dollar Amount
Aggregate Limit
Project Limit
Identify all sources, amounts, and purposes of money loaned to your firm including from financial institutions. Identify whether you the owner and any other person or firm loaned money to the applicant DBE/ACDBE. Include the names of any persons or firms guaranteeing the loan, if other than the listed owner (provide copies of signed loan agreements and security agreements)
Name of Source
Address of Source
Name of Person Guaranteeing the Loan
Original Amount
Current Balance
Purpose of Loan
1
2
3
List all contributions or transfers of assets to/from your firm and to/from any of its owners or another individual over the past two years (attach additional sheets if needed)
Contribution/Asset
Dollar Value
From Whom Transferred
To Whom Transferred
Relationship
Date of Transfer
1
2
3
List current licenses/permits held by any owner and/or employee of your firm
Name of License/Permit Holder
Type of License/Permit
Expiration Date
State
1
2
3
List the three largest contracts completed by your firm in the past three years, if any
Name of Owner/Contractor
Name/Location of Project
Type of Work Performed
Dollar Value of Contract
1
2
3
List the three largest active jobs on which your firm is currently working
Name of Prime Contractor and Project Number
Location of Project
Type of Work
Project Start Date
Anticipated Completion Date
Dollar Value of Contract
1
2
3
Submit
Should be Empty: