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CERTIFICATION APPLICATION

State of Indiana Department of Administration Minority and Womens Business Enterprises Division Indiana Government Center South 402 W. Washington Street, Rm. W469 Indianapolis, IN 46204-2744 www.in.gov/idoa/minority (317) 232-3061

City of Indianapolis Division of Equal Opportunity City-County Building 200 E. Washington Street, Suite 1501 Indianapolis, IN 46204 http://www.indygov.org/doa/deo.htm (317) 327-5262

Revised January 2005

MEMORANDUM OF UNDERSTANDING
Between the Indiana Department of Administration and the City of Indianapolis

WHEREAS the Indiana Department of Administration, Minority and Womens Business Enterprises Division is authorized to identify and certify minority and womens business enterprises and to maintain a central certification file; and WHEREAS the City of Indianapolis is authorized to identify and certify minority and womens business enterprises for City of Indianapolis projects and to maintain a central certification file; and WHEREAS in order to provide an efficient and reasonable procedure for the certification of minority and womens business enterprises, the parties desire to enter into an understanding concerning the reciprocity procedure by which each shall receive and utilize information submitted by applicants to either organization. NOW THEREFORE the parties agree as follows: 1. Initial certification will require that the following information be sent as requested by any other party for their review and assessment: a. b. c. d. e. f. 2. 3. 4. Certification Applications Birth Certificate or Ethnic Documentation Certification / Denial Letter Documentation of Initial Contribution Lease Agreement [1st page and signature page(s)] Onsite Review Report

Copies of onsite reviews shall be dispersed to the other parties as requested. Copies of recertification applications shall be provided to the parties upon issuance. Each party may request from the other parties such additional information provided by applicants and as would be otherwise available as a public document. Tax papers and financial records are not shared.

This Memorandum of Understanding between the State of Indiana and the City of Indianapolis does not infer that any party is required to accept the decision of any other party to this Memorandum or that any party is authorized to make decisions for any other party hereto. Each party retains all rights and responsibilities under their authorizing documents to make independent decisions on applications. This Memorandum is executed solely for the purpose of providing for reciprocity of information and application forms utilized by applicants for certification by any party.

Minority and Womens Business Enterprises Division Indiana Department of Administration

Division of Equal Opportunity City of Indianapolis

APPLICATION FOR CERTIFICATION
INSTRUCTION BOOKLET

This booklet is designed to assist in completing the MBE/WBE Application for Certification. Please refer to the question number and the number corresponding to it in this booklet. Questions that do not apply to your firm should be marked N/A in the space provided. All questions must be answered and the requested documents submitted to the department along with the application. Failure to do this will delay the processing of the application. Failure to answer all questions and/or submit all documentation will result in your application being returned to you. If you have additional information that is not requested in the application but will help prove that your firm is eligible, please attach this information to your application. Please return the completed application to the appropriate address below:

Indiana Department of Administration Minority and Womens Business Enterprises Division 402 W. Washington Street,Rm. W469 Indianapolis, Indiana 46204

City of Indianapolis Division of Equal Opportunity 200 E. Washington Street, Suite 1501 Indianapolis, IN 46204

Statement and Purpose
The Indiana Department of Administration and the City of Indianapolis have developed a certification application to determine whether your firm is eligible for certification and contracting programs. To qualify as a Minority Business Enterprise (MBE) or a Women Business Enterprise (WBE), your firm must meet the eligibility standards established by the certifying agency, a copy of which is attached. You are strongly encouraged to familiarize yourself with these regulations before submitting your application. Instructions for completing this application are attached. We urge you to take advantage of city and state contracting opportunities offered under this program by filling out the attached application. If you need assistance, or have questions regarding completion of the application, please contact the appropriate office listed in this document.

Upon receipt of the completed Application for Certification, the Department will evaluate the information submitted to determine compliance with the criteria. It is, therefore, imperative that your application and any attached documentation provide evidence of the ownership and control of your firm. You must also show that your firm has the resources necessary to perform the work you indicated. Only those firms which have been certified under this process can be considered for participation in both or one of the MBE and WBE programs. To ensure a timely review of your application, you must answer all questions and submit all requested documentation. If your firm was established in the past 2 years, and portions of the application do not seem applicable, please place (N/A) on the questions that do not apply. Failure to complete portions of the application and to submit the requested documentation will delay the certification process. The effort you make in submitting a complete application, the documentation requested and any other documentation that will help prove your firm meets the eligibility standards will decrease the amount of processing time. Since it is intended to prevent abuse of the program, the application is in the form of a SWORN AFFIDAVIT. The information requested is for certification purposes only and will be kept confidential to the extent allowed by law. Some portions of the certification application and/or documentation may be released under the Freedom of Information Act. ANY FALSE INFORMATION SUBMITTED BY APPLICANTS WILL BE CONSIDERED AS GROUNDS FOR DENIAL/DECERTIFICATION AND FOR PROSECUTION.

Right of Refusal
Firms located outside of Indiana must be certified by their home state prior to certification consideration. Each state shall have the right to refuse certification of a firm despite the fact that said firm may be certified. Also, the Indiana Department of Administration and the City of Indianapolis have the right to make independent decisions as they deem necessary.

Instructions For Completing Application For Certification
All companies wishing to be certified through our agency must obtain a Business Registration Number (BRN). Applications without a BRN can not be processed. To obtain your BRN visit the following website: http://www.in.gov/idoa/opportunityIN/. Problems and/or questions can be directed to (317) 232-6870 during normal business hours

Question 1 Question 2

Name of firm (DBA, if appropriate). Also attach a copy of your assumed business name certificate.

Main address of firm. This should be the address of the main or corporate offices. P Box numbers alone are not acceptable. .O. Additional offices should be listed on a separate attachment. Person or persons whom the department can contact for answers to questions about the application. Main business telephone number including area code, facsimile and e-mail.

Question 3 Question 4

Question 5 (A and B)

A. Place an "X" in the space in front of the type of firm which is applying for certification. Provide copies of the original and all amended partnership agreements obtained from the appropriate governmental agency. Provide copies of all stock certificates issued, including all cancelled certificates. B. The average number of full-time employees hired during the year. A. Date firm established. B. Date when current owners purchased the majority ownership of the firm. C. Answer question as indicated. If space is insufficient to identify previous firm names used, attach a separate sheet which includes all business names previously used by any owner, partner or stockholder who has at least 5 percent ownership in the firm applying for certification. A. B. C. D. E. Provide information requested. If certified as SBA 8a, attach a copy of the certification. If firm is certified by other governmental agencies, attach a copy of certification(s). If firm is certified by other governmental agencies, attach a copy of certification(s). Answer questions as indicated.

Question 6 (A through C)

Question 7

Question 8 (A through E)

Question 9 (A through C)

The detailed work resume should include, but not be limited to: The various jobs or positions of each owner in the past and to date, the general description of his/her duties and responsibilities and the dates of employment or ownership. Where applicable, former education should be included. A. After completing the personal information requested on each owner, place an "X" on those lines that apply to the individual. You should attach copies of one of the following documents which will prove your membership in the ethnic group you marked "X". Membership letter or certificate of an ethnic organization Tribal certificate Bureau of Indian Affairs card Birth Certificate Passport Armed Service discharge papers or other appropriate documentation Baptismal Certificate Any other documentation that provides evidence of your ethnicity For proof of citizenship, submit copies of a Birth Certificate, Voter's Registration Card, Armed Services Discharge Papers or other appropriate documentation that validates the response. For proof of legal permanent resident status, submit the document which includes Registration number. This proof is required. Attach proof of the initial investment in the firm (dollars, real estate and equipment), on behalf of each of the owners. B. This section must be filled in completely and if the officer is not an owner identified in item 9A, a work resume must be included (see item 9A for what the resume should include). C. This section must be filled in completely and if the number of directors are more than four, attach a separate sheet of paper with the other names and the requested information (see item 9A for what the resume should include). List individuals responsible for the management areas indicated, If more than one, please indicate. Work resumes must be included (see item 9A for what the resume should include). Be sure to include work resumes for your field superintendents.

Question 10 (A through I)

Instructions For Completing Application For Certification (continued)
Question 11 (A & B)
A. Provide information as requested. B. List those persons in your firm who are currently working for any other business which has a relationship with this firm, whether on a full-time or part-time basis as an owner, partner, shareholder, advisor, consultant or employee. A. Provide information as requested. If more than one individual or company, please indicate. This would include any firm or person who provides any type of management or technical services who is not an employee of this firm. If additional space is needed, attach a separate sheet. B. Provide information requested. C. Provide information requested. D. Provide information requested on those firms which have extended your firm credit, or signed letters from them indicating their willingness to extend your firm credit. E. Provide information requested. Provide a separate listing of owned equipment and a separate listing of leased equipment. Copies of the state registration cards and titles must be provided for all cars, trucks and other vehicles that require state registration/licensing. Copies of documentation of ownership for all equipment owned must be attached. A copy of the current executed leases for automotive equipment must be attached. A copy of the current leases for office space, storage space, parking space and any other spaces must be attached.

Question 12 (A through E)

Question 13

Question 14 (A through D)

A. Provide information as requested. Provide copy of the signed Corporate Bank Resolution(s) and/or bank account(s) signature card(s). B. Provide a signed statement from your bonding agent that verifies your bonding limits. C. Provide information as requested. D. Provide information as requested. Submit copies of required information. Be sure to identify the individual's name or firm that the license is issued to. If trucking is an area identified, an Interstate or Intrastate Authority is required. Provide a copy of the Authority. Provide information as requested. You must provide a copy of all denial and decertification letters received. A. Provide gross amount earned for each of last three years. B. Provide information on the work that your firm has completed in the past three years or for the length of time the firm has been in business. C. Provide information on the projects your firm is currently working on. Provide names and signatures of partners who have authority to execute contracts. If you are a supplier, provide the information requested. If not, mark n/a. A. List the products / services which you provide and are seeking certification. B. Provide the UNSPSC (United Nations Standard Products & Services Code) for the products / services for which you are seeking certification. You may obtain these codes by visiting http://www.unspsc.org/. You may browse and download the current version of the code and audit files at no cost. Companies applying for certification must be registered with the State of Indiana Secretary of States office. Their telephone number is 317-232-6576. Indicate which region of the state you prefer to work in (see attached map). Select your type of business by marking with an X. Answer as indicated. The Affidavit must be signed by the President or Chief Executive Officer of the firm and the Corporate Seal affixed to it. The Affidavit must also be notarized. False statements shall make your firm subject to decertification or denial of future certification. For a not-forprofit organization, the highest ranking officer must sign the affidavit.

Question 15

Question 16

Question 17 (A through C)

Question 18

Question 19 (A through D) Question 20 (A and B)

Question 21

Question 22 Question 23

Question 24 and 25 Affidavit

APPLICATION FOR CERTIFICATION
State Form 46250 (R8 / 1-05)

** Questions that do not apply to your firm should be marked N/A in the space provided. All questions must be answered and the requested documents submitted to the department along with the application. Failure to do this will delay the processing of the application.
Bidder registration number (must be provided) Check which type of program you are interested in

NOTE: If after filing this application, and prior to the expiration of your certification, there is any change in the ownership and/or management of this firm, you must submit a new Application for Certification to your home state.
Indicate which one your firm is capable and willing to seek contracting opportunities with

State of Indiana
1. Authorized name of firm

City of Indianapolis

Gaming Commission (Casinos)

Minority Business (MBE)

Women Business Enterprise (WBE)

2. Street address of firm (P .O.Box number alone is not acceptable) Mailing address of firm 3. Name of contact person 4B. Facsimile 5A. Type of firm 4C. E-mail City County State 4A. Business telephone ZIP code

(

)

Sole Proprietorship Partnership Corporation Other: _____________________________________________ If firm is a partnership, copies of all partnership agreements and the assumed name certificate must be attached (if applicable). If firm is a corporation, Articles of Incorporation, copies of stock certificates (both sides), Shareholders' Agreement, all minutes of the shareholders' meetings and Board of Directors' meetings, the Corporate Bylaws and Bylaws Amendments, the Corporate Bank Resolution and/or Bank Signature Cards must be attached. See the attached Certification Documentation Checklist for more detail.

B. What is the number of the firm's annual full-time work force? 6A. Date business was established (month, day, year) B. Date current owner(s) purchased the majority ownership C. Has your firm applied for reorganization under Chapter 11, of the firm (month, day, year) and/or liquidation under Chapter 7, within the last 3 years?

Yes
7. Has your company applied for certification in the past? If so, list the names that have been used previously

No

Yes

No
B. Are you an SBA 8a certified business? C. Is this firm currently certified as a DBE, MBE or WBE with its own state?

8. Identification Numbers and Certification:
A. Federal Identification number

Yes

No

If Yes, attach a copy of Certification

Yes Yes

No No

If Yes, attach a copy of Certification

D. If you are certified as a DBE, MBE, or WBE by any other federal, state or local agency, please attach a copy of your certifications.

E. Has this firm's home state conducted an on-site visit within the last year?

9. Ownership (work experience resumes of each person must be attached) A. Identify all individuals or holding companies and list their cash, equipment and/or real estate investment in the firm; and attach the documentation of the source of these investments. (If additional space is required, submit an attached sheet)
Name Home address (street and number) Sex (gender) Ethnic group City Home telephone number

(
State

)
ZIP code

Male

Female

Number of years owned Percentage owned

%
U.S. citizen

Black Hispanic Native American Caucasian Multi-Racial Yes No

Asian Pacific Asian Indian Other (explain)

Initial investment to acquire ownership interest in firm: Type Dollars Real Estate Equipment
Home telephone number

Dollar Value $ $ $

Legal permanent resident (submit proof of status)

Yes
Name

No

(
Home address (street and number) Sex (gender) Ethnic group City State

)
ZIP code

Male

Female

Number of years owned Percentage owned

Black Hispanic Native American % Caucasian Multi-Racial

Asian Pacific Asian Indian Other (explain)

Initial investment to acquire ownership interest in firm: Type Dollars Real Estate $ $ $ Dollar Value

U.S. citizen

Legal permanent resident (submit proof of status)

Yes

No

Yes

No

Equipment

-1-

9A. Ownership (continued)
Name Home address (street and number) Sex (gender) Ethnic group City Home telephone number

(
State

)
ZIP code

Male

Female

Number of years owned Percentage owned

%
U.S. citizen

Black Hispanic Native American Caucasian Multi-Racial Yes No

Asian Pacific Asian Indian Other (explain)

Initial investment to acquire ownership interest in firm: Type Dollars Real Estate Equipment
Home telephone number

Dollar Value $ $ $

Legal permanent resident (submit proof of status)

Yes
Name

No

(
Home address (street and number) Sex (gender) Ethnic group City State

)
ZIP code

Male

Female

Number of years owned Percentage owned

Black Hispanic Native American % Caucasian Multi-Racial

Asian Pacific Asian Indian Other (explain)

Initial investment to acquire ownership interest in firm: Type Dollars Real Estate $ $ Dollar Value

U.S. citizen

Equipment $ Yes No Yes No B. Identify officers (work experience resumes of each person must be attached). If additional space is required, submit an attached sheet. Name Title Ethnicity Gender Date Appointed

Legal permanent resident (submit proof of status)

C. Identify current Board of Directors (work experience resumes of each person must be attached). If additional space is required, submit an attached sheet. Name Title Ethnicity Gender Date Appointed

10. Indicate management personnel who control the firm in the following areas. (Attach work experience resumes, including dates of employment at each company, for each person). If more than two persons, please attach a separate sheet. A. Financial Decision: (responsibility for check signing, acquisition of lines of credit, surety bonding, supplies, etc.) Name Title Ethnicity Gender

B. Estimating: (cost estimates, bid preparation or negotiations) Name

Title

Ethnicity

Gender

C. Hiring/firing of management personnel: Name

Title

Ethnicity

Gender

-2-

D. Field/Production Operations Supervisor: (site supervision/scheduling, project management services) Name Title

Ethnicity

Gender

E. List all field supervisors: Name

Title

Ethnicity

Gender

F Contract signature authority: (contract execution, bid submission) . Name

Title

Ethnicity

Gender

G. Office management: Name

Title

Ethnicity

Gender

H. Marketing/Sales: Name Title Ethnicity Gender

I. Purchasing of major equipment: Name

Title

Ethnicity

Gender

11A. Do any of the people listed in questions 9 and 10 perform a management or supervisory function for any other business?

Yes

No

If Yes, identify the person, their title, business and the person's function.

B. Do any of the persons listed in questions 9 and 10 own or work for other firms which have a business relationship with yours? (Relationships include: ownership interest, shared office space, financial investments, equipment leases or personnel sharing.)
12. Identify persons or firms who provide the following services:

Yes

No

If Yes, identify the firm, the person and the business relationship.

A. External management or technical/computer service
Name of firm Address Name of person T elephone number

( B. Accountant
Name of firm Address Name of person

)

T elephone number

( C. Attorney
Name of firm Address Name of person

)

T elephone number

(

)

-3-

12D. Principal Suppliers:
Name of firm Address Materials or equipment supplied Name of firm Address Materials or equipment supplied Name of person T elephone number Name of person T elephone number

(

)

(

)

E. Identify those union(s), business or professional association(s) in which the owner(s) or management personnel have membership:
Name of union, business or professional association Address Name of union, business or professional association Address Name of union, business or professional association Address T elephone number T elephone number T elephone number

(

)

(

)

(

)

13. Attach a list of construction equipment and/or vehicles in your possession or under your control (indicate separately) and a list of office equipment, office space (owned or leased) and storage space (owned or leased), including signed leasing agreements. 14. Financial Information: A. Provide the following banking information:
Name of bank Address of bank Name of officer T elephone number

( B. If you have bonding capacity, identify the agent or broker and the bonding limit:
Name of agent or broker Address of agent or broker

)

Bonding limit

$
T elephone number

C. Provide copies of year end balance sheet and profit and loss (income) statements for the last three (3) years, or if a new business, provide a current balance sheet, a projected profit and loss statement for the next twelve (12) month period and a projected balance sheet for the end of that period. D . Identify all sources, amount and purposes of money loaned to the firm, including name of person securing the loan, if other than owner. Provide copies of all loan agreements. Name of Source Address of Source Amount

$ $ $
15. Current licenses (e.g. contractor, engineer, architect, ICC, etc.) Name of Individual or Firm Name of License Date of Expiration License Number

-4-

16. Has this firm or any of its owners, Board of Directors, officers or management personnel been denied or decertified DBE, MBE or WBE certification before by any agency in any state? Yes No If Yes, indicate the state, the name of the agency and the date.
State Name of agency Date (month, day, year)

Provide a copy of the denial or decertification letter(s).
17A. Specify the gross receipts of the firm for the last three (3) years. Year ending: T otal receipts = $ Year ending: T otal receipts = $ Year ending: T otal receipts = $ B. List the three (3) largest contracts completed in the past three (3) years:
Name of owner/contractor Name of owner/contractor Name of owner/contractor Name/location of project Name/location of project Name/location of project

C. List three active jobs this firm is currently working on:
Name of prime contractor and project number Name of prime contractor and project number Name of prime contractor and project number Location of project Location of project Location of project Date project began Date project began Date project began Anticipated completion date Anticipated completion date Anticipated completion date

PERSONS AUTHORIZED TO EXECUTE CONTRACTS

18. All partners must sign contracts unless a power of attorney is supplied modifying this. In the case of a corporation, only those signatures listed will be accepted. For a not-for-profit organization, the highest ranking officers signature is needed. The following persons are duly authorized to execute contracts and related documents on behalf of:
Name of company

NAME AND TITLE (type or print)

AUTHORIZED SIGNATURE

19. As a supplier, please address the following:
A. How large of an inventory do you maintain?

B. Where do you maintain your inventory?

C. From whom do you purchase your inventory?

D. Type of delivery system used?

-5-

20A. List type of work firm has performed or desires to perform under certification. (Be very thorough.)

B. Provide your firms UNSPSC codes for these services.

21. Is your business registered with the Indiana Secretary of States office?

If yes, please provide number

Yes

No

22. Indicate which region(s) of the state you prefer to work in (see map)

23. Type of business

Contractor

Subcontractor

Consultant

Supplier

Vendor

Service Professional

Service Organization

FOR FIRMS WISHING TO DO BUSINESS WITH THE CITY OF INDIANAPOLIS
24. Indicate the trade in which your business is engaged.

Construction

Retail

Supplier / Distributor

Manufacturer

Service

Broker

Other: ______________________
(Please indicate)

25. Does any principal in your firm, or the spouse of any principal, owe any money to the firm?

Yes

No AFFIDAVIT OF CERTIFICATION

The undersigned swears or affirms that the foregoing statements are true and correct and include all material information necessary to identify and explain the operations of ___________________________________________________________________
(Name of company)

as well as the ownership thereof. Any misrepresentation will be grounds for terminating any contract which may be awarded and for initiating action under federal or state laws concerning false statements.

Signature of owner, officer or partner

Date signed (month, day, year)

NOTARY CERTIFICATE STATE OF COUNTY OF

}

SS:

Subscribed and sworn to before me this __________ day of _______________________________________, 20 _______.
Signature of Notary Public Printed or typed name of Notary Public

County of residence

Date commission expires

-6-

Gary

South Bend

1

2
Fort Wayne

5
Lafayette West Layfayette

Kokomo

4 7

3
Muncie

8

Region 13 - Covers the entire state

6
Terre Haute Bloomington

Indianapolis

10 12
New Albany

9
Madison

11
Evansville

INDIANA DEPARTMENT OF ADMINISTRATION MINORITY AND WOMENS BUSINESS ENTERPRISES DIVISION CERTIFICATION DOCUMENTATION CHECKLIST

Name of company

All applicants must provide the documentation listed under ALL APPLICATION plus the additional documentation requested for their type of firm (i.e. An out-of-state sole proprietor must provide the documentation requested under ALL APPLICATIONS, SOLE PROPRIETOR and OUT OF STATE FIRMS.) Please write n/a or none next to any item that does not apply to your company and include an explanatory note. Copies of these documents are sufficient. ITEM
ALL APPLICATIONS NOTE: Re-cert apps. dont need to provide items marked with * unless they have changed. Birth certificate of owners * Ethnic documentation, drivers license, passport, naturalization certificate of owners. Work resume of all owners, officers and personnel listed on the application (application item 9) - resumes should cover the past 3 years, please do not send biographical sketches Proof of initial investment - All owners (application item 9) * - receipts, bank statements, both sides of canceled checks, etc. Proof of company owned real estate (title, warranty deed, tax or mortgage statement) Titles or registrations to any company owned vehicle leases (application item 13) Signed loan agreements or promissory notes (application item 14D) Relevant licenses (application item 15) List of active contracts (application item 16C) Notarized signature on affidavit of certification (page 7 of application) List of all company equipment and equipment leases (inlcude office equipment)

PROVIDED FOR OFFICE USE ONLY
VERIFIED DATE

SOLE PROPRIETORS Personal tax returns for past 3 years Past 3 years company income statements & balance sheets

PARTNERSHIPS Personal tax returns for past 3 years for all owners Partnership tax returns for past 3 years Partnership agreement (original and any amended versions) * Past 3 years company income statements & balance sheets

CORPORATIONS Articles of incorporation (original and any amendments - include filing copy with state seal/stamp)* By-laws (original and any amendments) * Minutes of stockholders & board meetings (past 3 years) Stock certificates (both sides) * Stock ledger (include names, certificate numbers, dates, transfers, cancellations) * Corporate bank resolutions and/or bank signature card(s) * Personal tax returns for past 3 years for all owners Corporate tax returns for past 3 years Past 3 years company income statements & balance sheets Annual salaries of all owners, officers, managers and directors for the previous year

Page 1 of 2

INDIANA DEPARTMENT OF ADMINISTRATION MINORITY AND WOMENS BUSINESS ENTERPRISES DIVISION CERTIFICATION DOCUMENTATION CHECKLIST

Name of company

ITEM
LLCS AN SUB-CORPORATIONS Articles of organization (original and any amendments - include filing copy with state seal/stamp) * Operating agreement (original and any amendments) * Corporate bank resolutions and bank signature card(s) * Personal tax returns for past 3 years for all owners Corporate tax returns for past 3 years Past 3 years company income statements & balance sheets

PROVIDED FOR OFFICE USE ONLY
VERIFIED DATE

OUT OF STATE FIRMS Must provide proof of current home state certification (letter and/or certificate) - include on-site review COMMENTS

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