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
1
- -
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
3
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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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