MINORITY AND WOMEN BUSINESS ENTERPRISE …

MINORITY AND WOMEN BUSINESS ENTERPRISE CERTIFICATION

APPLICATION

Form MWBE_1 Rev. 02/19/2019

Governor Matthew G. Bevin Commonwealth of Kentucky

Administered by Finance and Administration Cabinet Office of EEO and Contract Compliance

702 Capital Avenue Capitol Annex Room 395 Frankfort, Kentucky 40601

502-564-8099

MWBE APPLICATION FOR CERTIFICATION

SECTION I.

PROGRAM ELIGIBILITY

1. Is your Business at least 51% majority owned by women or racial/ethnic minorities?

Yes

2. Are the minority or women owners United States Citizens or Lawfully Admitted Permanent Residents of the United States?

3. Is your Business located in the United States? 4. a. Have the current minority and women owners owned and operated the Business for at least one year?

b. Date operations started: __________ (month) __________ (year)

c. Has the Business been continuously operating for at least one year?

Yes Yes Yes

Yes

5. a. Have the current women or minority owners filed at least one year of federal tax returns for the Business?

b. Have the current women or minority owners filed federal Business and personal tax returns for the most recently completed tax year?

6. a. Out-of-State Businesses ONLY: Is the Business currently certified as a DBE, MBE or WBE in its own state?

b. Out-of-State Businesses ONLY: Has the governmental certifying body in the state where your principal place of business is located conducted a physical onsite review at your place of business within the past three (3) years?

Yes

Yes Yes

Yes

No No No No

No No No No No

(X) STOP! If your answer to ANY question in this section was NO, then you DO NOT qualify for this program and do not need to fill out this application.

SECTION II. GENERAL INFORMATION

1. 1. Legal Name of Business:

2.

3. 2. Street Address of Business (P.O. Box number alone is not acceptable):

4.

5.

City:

7.

County:

6.

8.

9. State: 10. Zip Code:

11. 3. Mailing Address of Business (if different from Street Address): 12.

13. 4. Full Name of Primary Contact Person: 14.

17. 6. Facsimile Number:

18.

(

)

19. 7. E-mail:

21. 9. Form of Business: (Please Choose One)

Sole Proprietorship

Limited Liability Corporation

Partnership

Professional Services Corporation

Other (identify):

15. 5. Telephone Number:

16.

(

)

20. 8. Web Page:

Corporation Limited Partnership

Limited Liability Partnership

1. 10. Does your Business have an S-Corp election? If `yes', provide the S Election Effective Date _______________________________

Yes

No

2. 11. Has your Business ever existed in a different form or under a different name?

3.

4.

If `Yes', identify:

Yes

No

Form MWBE_1 Rev. 02/19/2019

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- -

22. 12. Is the Address in Section II, Question 2 your Principal Residence?

23. 13. Does your Business operate at more than one (1) location?

24.

If `Yes', please list other location(s) by city and state:

Yes Yes

No No

25. 14. Is your Business registered with the Kentucky Secretary of State's Office?

Yes

No

26. 15. Method of Acquisition (check all that apply):

Merger or Consolidation

Inherited Business

Started New Business Myself

from ____________________________________

Bought Existing Business

from ____________________________________

Other (explain):____________________________

Gift from _________________________________

_________________________________________

_________________________________________

27. 16. Type of Business (select one primary business category from the choices listed):

Consultant

Contractor

Subcontractor

Supplier/Distributer

Manufacturer

Professional Services

Retail

Nonprofessional Services

Broker

Private Foundation

Other (identify):________________________________

5. 17. List the activities, products or services of the Business: 6.

7. 18. List your business's primary NAICS code. _____________________

8.

9. 19. Identify the type of federal tax return filed by the Business for each of the last three (3) years, i.e. 1120, 1120S, 1065, Schedule C (sole

10.

proprietor only, etc.):

11.

Tax Year: __________ Filed Form: __________________________________

12.

Tax Year: __________ Filed Form: __________________________________

Tax Year :__________ Filed Form: __________________________________

13. 21. Has your Business applied for reorganization under Chapter 11, and/or liquidation under Chapter 7, within the last 3 years?

Yes

No

14. 22. List your business's FEIN, if applicable (Do NOT list your social security number):

15.

______________

SECTION III. CERTIFICATION INFORMATION

1. If certified by the Commonwealth of Kentucky, do you intend to use the certification to qualify for MBE or WBE

program opportunities in other states?

Yes

No

2. Is your Business currently certified by any of the following programs?

Yes

No If `Yes,' identify the program (check all

that apply):

KY Transportation Cabinet DBE Program

U.S. Small Business Administration 8(a) Program

Other State Certification Entity (identify): ____________________________________________________________________

3. Has your Business or any of its owners, Board of Directors, officers or management personnel ever been denied or decertified DBE, MBE or WBE certification before by any agency in any state?

Yes

No

If `Yes,' please provide the following:

State that Denied or Decertified Name of Agency

Date

Reason for Denial or Decertification

Form MWBE_1 Rev. 02/19/2019

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SECTION IV. RELATIONSHIPS WITH OTHER BUSINESSES

16. 1. Is your Business co-located at any of its business locations OR does your Business share a telephone number,

P.O. Box, office space, storage space, yard, warehouse, facilities, equipment, inventory, financing, office staff

Yes

and/or employees with any other business(es), organization(s), entity(ies) or individual(s)?

No

If `Yes', explain the nature of the relationship by providing the following information:

17.

a. Name of other business(es), organization(s), entity(ies) or individual(s) with whom you have any formal, informal, written, or oral

18.

agreement:

19.

20.

b. Identify and list each shared resource (examples include telephone number, P.O. Box, office space, storage space, yard, warehouse,

21.

facilities, equipment, inventory, financing, office staff and/or employees):

22.

c. Explain the nature of the shared resources:

23. 2. Do any other businesses, organizations, or entities presently hold an ownership interest in your Business?

24.

If `Yes', identify:

25. 3. Have any other businesses, organizations, or entities previously held an ownership in your Business?

26.

If `Yes', identify:

27. 4. Do any of your immediate family members own or manage another business?

28.

If `Yes', please list:

Yes

No

Yes

No

Yes

No

29.

Name of Family Member 30. Relationship

31. Type of Business 32. Own or Manage

33. 5. Do any minority or women owners have an ownership interest in any other business(es)?

34.

If `Yes', please list:

35. Name and Address of Business

37. Name of Owner

36.

Yes

No

38. Ownership Percentage

Form MWBE_1 Rev. 02/19/2019

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SECTION V. OWNERSHIP

39.

40. 41. 42. 43.

47. 48. 52. 53. 56.

Identify all individuals or entities holding an ownership interest in the Business and list their initial investment (cash, property, equipment and other) in the Business.

Owner 1

Name:

City:

Percentage of Business Owned:

Race/Ethnicity (check all that apply):

African American Subcontinent Asian American

44. Home Telephone Number: 46.

45. (

)

Home Address (Street and House Number):

49. State:

50.

Zip Code:51.

Number of Years Business

Owned:

54.

U.S. Citizen:

55. Lawfully Admitted

Yes

No Permanent Resident:

Yes

No

57. Sex:

Asian Pacific American

Hispanic American

Male

Native American

Caucasian

Female

58.

Initial investment to acquire ownership interest in Business:

59.

Type

60.

Dollar Value

62.

Cash

63.

$

65.

Real Estate

66.

$

68.

Equipment

69.

$

71.

Other

72.

$

74.

If `Other,' explain in detail:

61. Date (Month and Year) 64. 67. 70. 73.

75.

Was ownership acquired with joint or marital assets?

Yes

No

76. Owner 2 (if applicable) 77.

78.

Name:

79. Home Telephone Number: 81.

80. (

)

Home Address (Street and House Number):

82.

City:

83.

84. State:

85.

Zip Code:86.

Number of Years Business

Owned:

87.

Percentage of Business Owned:

88.

89.

U.S. Citizen:

90. Lawfully Admitted

Yes

No Permanent Resident:

Yes

No

91.

Race/Ethnicity (check all that apply):

92. Sex:

African American

Asian Pacific American

Hispanic American

Male

Subcontinent Asian American

Native American

Caucasian

Female

93.

Initial investment to acquire ownership interest in Business:

94.

Type

95.

Dollar Value

97.

Cash

98.

$

100. Real Estate

101. $

103. Equipment

104. $

106. Other

107. $

109.

If `Other,' explain in detail:

96. Date (Month and Year) 99. 102. 105. 108.

110. Was ownership acquired with joint or marital assets?

Yes

No

Form MWBE_1 Rev. 02/19/2019

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