Division of Minority and Women’s Business Development

[Pages:5]Division of Minority and Women's Business Development

CERTIFICATION APPLICATION AFFIDAVIT

All applicants, including each business and each Minority or Woman owner being relied upon for certification, ("Applicant") must certify that they have reviewed and verified the truthfulness and accuracy of the statements contained in the Application for MWBE Certification or Recertification, as well as any attachments, documents or supplemental information submitted in support thereof, whether submitted electronically, verbally, or in paper format ("Application"), by signing this Affidavit. Further, all Applicants must agree to the following terms and conditions, which contain responsibilities of the Applicant, rights retained by the State of New York and penalties that may be applied for non-compliance with responsibilities and/or making any false, misleading and/or inaccurate representations.

This Affidavit and the Application, including any supplementary documentation or information submitted in support of the Application, shall be verified under oath by the business enterprise applicant and each minority and/or woman sole proprietor, owner, partner, member, shareholder and/or stakeholder relied upon for certification.

TERMS AND CONDITIONS

1. By submitting this Application, the Applicant acknowledges that the content entered into the electronic Application form, the supporting documents, and any other information provided in support of an Application, submitted via the (the "NYS Contract System") or submitted in paper form, verbal responses, or in any other manner, is deemed to be part of the Application. The Applicant recognizes and acknowledges that any information provided in support of the Application is given under oath, is true and accurate, and that any misrepresentation may be grounds for denial of certification, revocation of certification, and may result in the loss of an award and/or termination of any contracts which may have been awarded to the Applicant by the State of New York. In addition, the Applicant further understands that any misrepresentation made in conjunction with the Application is subject to both the civil and criminal laws of the State of New York.

2. The Department of Economic Development, Division of Minority and Women's Business Development ("DMWBD") is subject to the Freedom of Information Law ("FOIL"). The Applicant may request that DMWBD except all or part of a Contractor's proposal, reports or other information submitted to DMWBD from public disclosure, pursuant to Section 87(2)(d) of the Public Officers Law, on the ground that said specified item(s) contain trade secrets or that the information, if disclosed, would cause substantial injury to the competitive position of the applicant. The request for an exception must be in writing and must state the reasons why the information should be excepted from disclosure. It must also specify the items or portions thereof for which the exception is requested. DMWBD reserves the right to make the final determination of whether the information submitted by the Applicant may be withheld from disclosure under FOIL.

3. By submitting this Application, the Applicant acknowledges and agrees that DMWBD reserves the right to request evidence to prove minority or woman status, in addition to the information disclosed in this Application. By submitting this Application, the Applicant agrees to submit additional proof if it is requested. Applicant acknowledges and agrees that DMWBD reserves the right to reject an Application as a Minority or Women-Owned Business if the Applicant fails to respond to DMWBD within 20 days of a request by DMWBD.

4. By submitting this Application, the Applicant acknowledges that to be certified or recertified or to maintain its certification as an MWBE firm, the Applicant must demonstrate that, at all times, it meets all of the eligibility criteria for certification under NYS Executive Law, Article 15-A and the related regulations, regardless of any prior grant of certification made by DMWBD or other grant of certification made by any other agency or government entity.

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5. Applicant acknowledges and agrees that DMWBD may assign this Application to a third party as part of a Certification Assistance Program ("CAP") and that a third party may review the Application and make a recommendation concerning eligibility for certification based on the information submitted by the Applicant.

6. By submitting this Application, the Applicant consents to periodic examination of its current and prior Applications, books, records and an interview of its principals and employees by DMWBD and/or a site visit for the purpose of determining whether the Applicant is, or continues to be, an eligible Minority or Women-Owned Business. The Applicant acknowledges that its certification may be rejected, denied, or revoked if such examinations, requests for information or interviews are refused; or if DMWBD determines that, as a result of the examination or interviews, the Applicant does not qualify as a Minority or Women-Owned Business Enterprise.

7. By submitting this Application, Applicant consents to providing information and documents regarding work performed by the Applicant business to enable DMWBD to review, assign and/or remove services, commodities and/or industry classifications into the categories of labor, services, supplies, equipment, materials and recognized construction trades, including without limitation, the North American Industry Classification System ("NAICS") codes, National Institute of Governmental Purchasing ("NIGP") codes, Construction Specification Institute ("CSI") codes and/or NYS Department of Transportation ("NYS DOT") codes (collectively referred to as "Codes"). Applicant acknowledges, understands, and agrees that the directory of certified minority and women owned businesses, including the review, assignment, and/or removal of Codes is prepared by the Director of the Division for use by contracting agencies and contractors. Applicant further agrees and acknowledges that, after DMWBD has determined that the Applicant meets the eligibility criteria for certification, DMWBD shall have the power to review and make the final assignment of Codes or remove any Codes for an applicant business, based on the Applicant's documentary evidence of self-performed work.

8. Applicant acknowledges and agrees that certification, recertification, or the assignment of any Codes does not constitute a representation by the Division that any contract will be awarded to the Applicant by any third party.

9. By submitting this Application, the Applicant consents and agrees to respond to audits and requests for information that may be directed by DMWBD to the Applicant's holding or affiliate companies, bonding companies, banking institutions, credit agencies, contractors, clients and other certifying agencies for the purpose of ascertaining the applicant's eligibility for certification. If the Applicant impedes, interferes with or prohibits DMWBD from making such inquiries, such failure may be grounds for rejection of the Application or denial or revocation the Applicant's certification.

10. By submitting this Application, the Applicant agrees to keep the applicant business' contact information, including address, telephone number and email address, current and valid, on the NYS Contract System and on its application profile, and to notify DMWBD within 30 days of any changes. The Applicant further agrees to provide notice to DMWBD of any other changes to the business enterprise, including but not limited to cessation of business operation by the minority or woman owner, transfer or loss of ownership and/or management and control of the Applicant business enterprise by the minority or woman owner, or changes to the information contained in the Application or any documents submitted to DMWBD in support of an Application within 30 days of such change. Failure to notify DMWBD of any changes to the business enterprise may result in rejection of an Application or denial or revocation of certification.

11. With certain exclusions, certification is normally granted for a period of 5 years. By submitting this Application, the Applicant acknowledges and agrees that DMWBD may require the submission of a New Application, additional information, and/or examination of the Applicant's principals and/or employees at any time before the expiration of the 5-year certification period. The Applicant's failure to submit such material, or to consent to such examinations and interviews, shall be grounds for revocation of certification.

12. By submitting this Application, the Applicant consents to DMWBD's sharing of reports, summaries, reviews, analyses, recommendations and determinations related to this Application with other certifying agencies, that may request such information as a result of the Applicant submitting an application for certification to those agencies.

13. Applicant certifies that the personal net worth of each person upon which certification is based does not exceed $15 million and the Applicant firm does not employ more than 300 employees, unless a waiver has been requested and granted.

14. By submitting this Application, the Applicant agrees to submit completed Federal and State taxes to DMWBD, as required. Further, the Applicant authorizes the New York State Department of Taxation and Finance and the Department of Labor to disclose the Applicant's tax and/or employer information,

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with the DMWBD, for use in conjunction with the certification or recertification application process as well as any legal proceedings concerning the denial or revocation of certification, in accordance with Executive Law, Article 15-A, Section 314(2-c), and related regulations. 15. By submitting this Application, the Applicant consents to the electronic receipt of notifications and correspondence from DMWBD, including for example and without limitation, certification letters, requests for information or documents, denial letters etc., that may be transmitted to the Applicant via the NYS Contract System, email or any other electronic means or that may be viewable or accessible through the NYS Contract System. Applicant agrees that electronic submission of such notifications and correspondence constitutes actual, constructive, adequate notice if such notice was transmitted to the address or email address listed in the Applicant's profile on the NYS Contract System, as of the date of the transmission. 16. By submitting this Application, the Applicant acknowledges and agrees that it has a continuing obligation to comply with, and will continue to comply with, the requirements set forth herein as well as in Executive Law Article 15-A, 5 NYCRR Part 140, et al., and any other applicable law.

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AGREEMENT TO BE BOUND BY THE CERTIFICATION APPLICATION AFFIDAVIT

Agreement to be Bound by the Applicant Business (Each business enterprise must sign & have notarized.)

Under penalty of perjury, the business enterprise making this Application, whose corporate representative authorized to and has signed below on its behalf, certifies that the foregoing Certification Application Affidavit has been read and understood, that the statements and representations made in the Application or in any supplemental submissions are true and complete to the best of the business enterprise's knowledge and that the business enterprise agrees to the foregoing terms and conditions. The business enterprise further understands and acknowledges that any false or misleading representations made in connection with an Application will result in the rejection of the Application, denial and/or revocation of certification and is punishable as a Class E Felony under Section 175.35 of the New York State Penal Law.

Business Enterprise/Applicant

Authorized Corporate Representative & Title (Print)

Signature of Authorized Corporate Representative Subscribed and sworn to before me on this _____ day of_____________, 20___.

Notary Public

Agreement to be Bound by a Minority or Woman Owner of the Applicant Business (Each minority or woman owner

of the business enterprise must sign & have notarized; additional signature blocks are below.)

Under penalty of perjury, I certify that by signing below, I attest that I am an owner, sole proprietor, corporate officer, member or partner in the enterprise making the Application and a minority or woman owner being relied upon for certification, that I have read and understand the foregoing Certification Application Affidavit, that the statements and representations made in the Application or in any supplemental submissions are true and complete to my knowledge, and that I agree to the foregoing terms and conditions. I further understand and acknowledge that any false or misleading representations made in connection with an Application will result in the rejection of the Application, denial and/or revocation of certification and is punishable as a Class E Felony under Section 175.35 of the New York State Penal Law.

Name/Applicant & Title (Print)

Business Enterprise

Signature Subscribed and sworn to before me on this _____ day of_____________, 20___.

Notary Public

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Agreement to be Bound by a Minority or Woman Owner of the Applicant Business (Must be signed/notarized by each minority or woman co-owner relied upon for certification)

Under penalty of perjury, I certify that by signing below, I attest that I am an owner, sole proprietor, corporate officer, member or partner in the enterprise making the Application and a minority or woman owner being relied upon for certification, that I have read and understand the foregoing Certification Application Affidavit, that the statements and representations made in the Application or in any supplemental submissions are true and complete to my knowledge, and that I agree to the foregoing terms and conditions. I further understand and acknowledge that any false or misleading representations made in connection with an Application will result in the rejection of the Application, denial and/or revocation of certification and is punishable as a Class E Felony under Section 175.35 of the New York State Penal Law.

Name/Applicant & Title (Print)

Business Enterprise

Signature Subscribed and sworn to before me on this _____ day of_____________, 20___.

Notary Public

Agreement to be Bound by a Minority or Woman Owner of the Applicant Business (Must be signed/notarized by each minority or woman co-owner relied upon for certification)

Under penalty of perjury, I certify that by signing below, I attest that I am an owner, sole proprietor, corporate officer, member or partner in the enterprise making the Application and a minority or woman owner being relied upon for certification, that I have read and understand the foregoing Certification Application Affidavit, that the statements and representations made in the Application or in any supplemental submissions are true and complete to my knowledge, and that I agree to the foregoing terms and conditions. I further understand and acknowledge that any false or misleading representations made in connection with an Application will result in the rejection of the Application, denial and/or revocation of certification and is punishable as a Class E Felony under Section 175.35 of the New York State Penal Law.

Name/Applicant & Title (Print)

Business Enterprise

Signature Subscribed and sworn to before me on this _____ day of_____________, 20___.

Notary Public

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