MUSKEGON COUNTY
UNIFIED CERTIFICATION APPLICATION
FOR
DISADVANTAGED, MINORITY AND
WOMEN-OWNED BUSINESS
ENTERPRISES
APPLICATION FEE $25
May 2003
Last revised 2/25/04
MAY’ 2003
MUSKEGON COUNTY
UNIFIED CERTIFICATION PROGRAM
Introduction
Inclusion of minority, women and/or socially and economically disadvantaged-owned businesses in the economic mainstream of
America is a national imperative. As our nation becomes more and more diverse and recognizes the cultural and social constructs,
which perhaps are more natural than one would care to acknowledge, it becomes a growth and development necessity to diversify
the economic capacity of the citizenry. Leading national companies such as GM, FORD, CHRYSLER, etc. have discovered that to
remain competitive and leaders in their fields one must decisively diversify its supplier base.
GENERAL OVERVIEW
The Unified Certification Program is a county-wide effort focused on providing measurable exposure for minority, women and/or
socially and economically disadvantaged-owned businesses. The names and certification status of all known minority, women
and/or socially and economically disadvantaged-owned businesses shall appear in our local DBE and business directories. These
directories will be disseminated to all local government agencies, contractors and the general public. Agencies, contractors, etc. will
be encouraged to use the directories as a basic resource for soliciting minority, women and/or socially and economically-owned
disadvantaged businesses for participation in its projects and programs. Certification applicants are required to complete the
Muskegon County Purchasing Vendor registration via the internet at www.co.muskegon.mi.us.
Certification provides a mechanism for an agency, contractor, etc. to measure the effect and outcomes of its good-faith efforts
toward inclusion. The Unified Certification Program is meant only to authenticate the ownership and management of the business
enterprise. Assessing a business enterprise’s qualifications and capabilities remains the responsibility of the respective agency,
contractor, etc.
Certification determinations are processed by a certification review committee of the Supplier Diversity Conference Advisory Board
which will meet quarterly. Certification may take anywhere from three (3) to six (6) months from the date of receipt of a completed
application. An application fee of twenty-five ($25) dollars is required w/application. All information will be processed in the
strictest of confidence. The information sought is self-explanatory and typical of the kinds of things one would think about as they
structure their business operations. We do not anticipate that one would need to hire external assistance in completing the
application. In the event that clarification is needed on any questions in the application packet, you may contact the Muskegon
County EEO office at (231)724-6571 for assistance. Certification is good for three years.
Those firms, who already possess a certification from another agency, need only to complete and submit pages 4 –13, send in the
application fee and complete a vendor registration from the Purchasing Office. The firm need not complete or submit any other
portions of the certification. Certifications that will be accepted by Muskegon County are MMBDC, MUCP, and NAWBO.
DEFINITIONS
Certified means that the minority, woman or socially and economically-owned business has been authenticated as being at least 51%
owned and controlled either by minorities, females or socially and economically disadvantaged individuals for participation in
programs requiring certification as determined by the Unified Certification program participants.
Disadvantaged Business Enterprise (DBE) means small business:
a)
which is at least 51% owned by one or more socially and economically disadvantaged individuals, or in the case of any
publicly owned business, at least 51% of the stock which is owned by one or more socially and economically disadvantaged
individuals; and
b) whose management and daily business operations are controlled by one or more of the socially and economically
disadvantaged individuals who own it.
Minority means a person who is:
1) Black, which is a person having origins in any of the black racial groups in Africa; or
2) Hispanic, which is a person of Spanish or Portugese culture, with origins in Mexico, South or Central America, or the
Carribbean Islands, regardless of race; or
3) Asian American, which is a person having origins in any of the original peoples of the Far East, Southeast Asia , India
Subcontinent, Hawaii, or the Pacific Islands; or
2
4) Native American (American Indian or Alaskan native), which is a person having origins in any of the original peoples of
North America
Minority Business Enterprise (MBE) means a business that is:
a)
A sole proprietorship, partnership or joint venture owned and controlled by minorities in which at least 51% of the
ownership interest is held by minorities and the management and daily business operations are controlled by one or more of
the minorities who own it; or
b) A corporation or other business entity authorized under the laws of the United States whose management and daily business
operations is controlled by one or more minorities who own it and which is at least 51% owned by one or more minorities
or, if stock is issued, at least 51% of the stock is owned by one or more minorities.
Women Business Enterprise (WBE) means a business that is:
a) A sole proprietorship owned and controlled by a woman;
b) A partnership or joint venture owned and controlled by women in which at least 51% of the ownership is held by women
and the management and daily business operations of which are controlled by one or more women who own it; or
c) A corporation and other business entity authorized under the laws of the United States whose management and daily
business operations are controlled by one or more women who own it and which is at least 51% owned by women or, if
stock is issued, at least 51% of the stock is owned by one or more women.
CERTIFICATION STANDARDS and APPEALS
A firm seeking certification has the burden of demonstrating, by a preponderance of the evidence, that it meets the requirements
concerning group membership or individual disadvantage, business size, ownership, and control.
1.
2.
3.
Certification Denials - If a firm is denied certification, it will receive a written explanation of the reasons for the denial,
specifically referencing the evidence in the record that supports each reason for the denial. All documents and other
information on which the denial is based will be made available to the applicant, on request. Firms that have been denied
may not reapply until after six (6) months has elapsed.
Certification Removal – If a written complaint alleging ineligibility of a currently certified firm specifying the alleged
reasons why it’s ineligible is received, a review will be conducted. If during this review there is reasonable cause to believe
that the firm is ineligible, a written notice will be sent to the firm, setting forth the reasons for the proposed ineligibility
determination. If during the review there is not reasonable cause to believe that the firm is ineligible, a written notice will
be sent to the complainant and the firm, setting forth the reasons for such finding.
Certification Appeals – If a firm wishes to file an appeal of any determination made by the certification review committee,
it must send a letter to the Muskegon County Equal Opportunity Office within 90 days of the date of the final decision,
including information and arguments concerning why the decision should be reversed. The Equal Opportunity Office will
have 60 days to conduct a review and either affirm or repeal the denial. The Equal Opportunity Office’s determination is
final. A written letter of determination will be sent to the firm acknowledging the finding.
3
MUSKEGON COUNTY
DBE/MBE/WBE CERTIFICATION INITIATIVE
UNIFORM CERTIFICATION APPLICATION
General Instructions: (PLEASE TYPE OR PRINT CLEARLY. DO NOT LEAVE ANY SPACES BLANK ON THE APPLICATION.)
If a question is not applicable to your business insert “N/A” in the space provided for your answer.
You may make photocopies of the completed application as necessary.
Whenever the space is insufficient to answer the questions completely, attach additional sheets as necessary.
Use the question number to identify any answer continued on an additional sheet.
1a.
Name and Street Address of Applicant Firm (Enter the full legal name of the enterprise. For example, a corporation named
ABC Construction, Inc. should be identified as “ABC Construction, Inc.”, not as “ABC Construction”).
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
1b.
“Doing Business As” (D/B/A) Name
(Complete if firm does business under an assumed or trade name that is different from its legal name.)
___________________________________________________________________________________________________
1c.
Mailing Address (Complete if different from street address.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
2.
Business Phone Number: (
) ________________________
3.
Federal Employer Identification Number OR Social Security Number (A Federal Employer Identification Number is
required for most business activities. For an application and/or additional information, contact the U.S. Internal Revenue
Service at (800) 829 - 1040. Sole proprietorships may submit social security number of the owner in lieu of the federal
identification number.)
___________________________________________________________________________________________________
4a.
Name of Company President/Chief Executive Officer/Owner
______________________________
President
4b.
_____________________________
Chief Executive Officer
)_______________________________
___________________________
Owner
Name & title of officer of the firm who can be contacted during the application review process.
___________________________________________________
Name
5.
FAX: (
_________________________________________
Title
This Firm is applying for certification as: (Please refer to page 12 of this application to determine the appropriate
designation for your company. One or more categories may be designated.)
 Minority Business Enterprise (MBE)
 Women-Owned Business Enterprise (WBE)
 Disadvantaged Business Enterprise (DBE)
4
6.
Does this firm have current Small Business Administration (SBA) 8(a) status?
 Yes
7.
 No
If Yes, please attach a copy of the SBA letter of approval.
Are you currently involved in the bidding process or other contract/purchase order negotiations with any governmental
agency, department or authority?
 Yes
 No
If Yes, please identify agency, department or authority.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
8a.
Type or ownership (Please specify current ownership.)
 Sole Proprietorship _______________________ Certificate of Trade Name on file in __________________________
 Partnership _______________________ Business Certificate for Partners on file in _____________________________
 Corporation ______________________ Certificate of Incorporation on file in _________________________________
8b.
Did the business exist under a different type of ownership prior to the date indicated in question 8a?
 Yes  No
If Yes, Explain _________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
8c.
Has your Certificate of Incorporation or business certificate been amended?
 Yes  No
If Yes, Explain _________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
8d.
Method of Acquisition (check all applicable):
 Started New Business
 Secured Franchise
 Bought Existing Business
 Secured Concession
 Inherited Business
 Merger or Consolidation
 Other _________________________________
Date of Acquisition ______________________________
8e.
Name & Position of all person(s) with ownership interest. Check all that are applicable. (If no positions are held, state
‘none’.)
Name
Group
Code*
Position
%Owned
Sex
US Citizen or
Permanent
Resident Alien
___________________________ ____________________ _____
______
 Male  Female
 Yes
 No
___________________________ ____________________ _____
______
 Male  Female
 Yes
 No
___________________________ ____________________ _____ ______
*Group Code Key (Please refer to Page 16 for Definitions.)
01 - Black
02a - Hispanic
03a - Asian-Pacific
02b - Portuguese
03b - Asian-Indian
02c – Spanish
 Male  Female
 Yes
 No
5
04 - Native American
05 – Resident of Public Housing
05a – Low Income persons living
in areas where a HUD-assisted
project is located
9.
10a.
10b.
10c.
11.
Please identify the cash and capital contributions to the firm by those identified in 8e, including gifts, equipment, loans and
expertise.
Contributor
_________________________________
Amount/Value
__________________________
Type/Date of Contribution
__________________________________
_________________________________
__________________________
__________________________________
_________________________________
__________________________
__________________________________
_________________________________
__________________________
__________________________________
_________________________________
__________________________
__________________________________
If the firm is a partnership, please complete for all partners.
Name
_________________________________________
Total
Amount/Value
of Contributions
__________________________________
Date of
Ownership
____________________
_________________________________________
__________________________________
____________________
_________________________________________
__________________________________
____________________
_________________________________________
__________________________________
____________________
_________________________________________
__________________________________ ____________________
_________________________________________
__________________________________
____________________
If the firm is a corporation, please complete for all shareholders.
Name
_________________________________________
No of
Share
___________
Common
or
Preferred
____________
Amount
Paid When
Purchased
____________
Date of
Ownership
____________
_________________________________________
___________
____________
____________
____________
_________________________________________
___________
____________
____________
____________
_________________________________________
___________
____________
____________
____________
_________________________________________
___________
____________
____________
____________
If a corporation, number of shares:
Common Authorized ________________________
Common Issued ________________________
Preferred Authorized ________________________
Preferred Issued ________________________
Gross Receipts (Sales). Please provide gross receipts for the last 3 years. (If in business less than 3 years complete as
applicable.)
$ __________________________
Current Year (20______)
$ ____________________________
Last Year (20_______)
6
$ ________________________
Previous Year (20 _____)
12.
Number of employees (Please average over the past year.)
Permanent
Temporary
Full-Time _________________________
Part-Time _________________________
13.
14a.
Full-Time ____________________________
Part-Time ____________________________
If licensing, permits or accreditation is required to conduct the business, please identify:
Type or License/Permit
Issued by
Issue Date
Exp. Date
Holder/Registrant
__________________________________
____________
_____________ _____________ ___________________
__________________________________
____________
_____________ _____________ ___________________
__________________________________
____________
_____________ _____________ ___________________
__________________________________
____________
_____________ _____________ ___________________
Check all that best describe the business operation.
 Construction-Related
 Consumer Service
 Professional Service
 Manufacturer/Supplier
 Technical Service
 Retail
 Other (explain)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
14b.
Describe principal products/commodities sold, specialties or services offered (Please explain)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
15a.
Identify those individuals responsible for managerial operations (State if owner or non-owner.)
*For Group Codes, see Page 16.
Group
Name & Title
Sex
Code*
Owner or Non-Owner
1. Financial Decisions
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________  Male  Female
_________
 Owner  Non-Owner
2. Estimating
3. Preparing Bids
7
__________________________________
 Male  Female
_________
 Owner  Non-Owner
Name & Title
Sex
Group
Code*
Owner or Non-Owner
__________________________________  Male  Female
_________
 Owner  Non-Owner
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
__________________________________
 Male  Female
_________
 Owner  Non-Owner
4. Negotiating Bonding
__________________________________
5. Negotiating Insurance
6. Marketing & Sales
7. Hiring & Firing
8. Supervising Field Operations
9. Purchasing Equipment/Supplies
10. Managing & Signing Payroll
11. Negotiating Contracts
12. Signators for Business Accounts
8
15b.
Please identify additional staff persons. If any individual also works for another firm, please check yes and provide the
person’s name, his/her position, other firm’s name, address and telephone number.
Name & Position
Other Firm Name, Address
Phone
 Yes  No
_________________________________
__________________________________
(___)________
 Yes  No
_________________________________
__________________________________
(___)________
1. Office staff
2. Field/supervisory staff
 Yes  No
_________________________________
__________________________________
(___)________
 Yes  No
_________________________________
__________________________________
(___)________
 Yes  No
_________________________________
__________________________________
(___)________
 Yes  No
_________________________________
__________________________________
(___)________
 Yes  No
_________________________________
__________________________________
(___)________
 Yes  No
_________________________________
__________________________________
(___)________
3. Estimator
4. Controller
5. Consultant (for firms involved in providing consultant/technical service or advisory services)
15c.
 Yes  No
_________________________________
__________________________________
(___)________
 Yes  No
_________________________________
__________________________________
(___)________
If this firm shares the following with any other firm, please provide the other firm’s name, address & telephone number.
Other Firm Name
Address
Phone
1. Office Space
_________________________________________
___________________________________ (___)_________
_________________________________________
___________________________________ (___)_________
2. Yard space
_________________________________________
___________________________________ (___)_________
_________________________________________
___________________________________ (___)_________
3. Equipment (include rentals)
_________________________________________
___________________________________ (___)_________
_________________________________________
___________________________________ (___)_________
9
16a.
List rented, leased, or owned warehouse, plant, yard, and office facilities.
Facility type
16b.
If rented or leased,
Amount of yearly rent payments
___________________________ __________________________________
__________________________________
___________________________ __________________________________
__________________________________
___________________________ __________________________________
__________________________________
___________________________ __________________________________
__________________________________
List major equipment or machinery that is owned or leased by the firm.
Type
17.
Owner or name of
Lessor and/or rental agent
Depreciated
dollar value
Acquisition
date
Payment
terms
___________________________ __________________________
____________________ ____________________
___________________________ __________________________
____________________ ____________________
___________________________ __________________________
____________________ ____________________
___________________________ __________________________
____________________ ____________________
___________________________ __________________________
____________________ ____________________
___________________________ __________________________
____________________ ____________________
___________________________ __________________________
____________________ ____________________
Do any principals, officers and/or owners of the firm have an affiliation (i.e. business interest or employment) with any
other firm?  Yes
 No
If Yes, please complete the following:
Name of
Person
Firm name
& address
Phone
number
Nature of
business
Nature of
affiliation
____________________ ____________________ (___)_________ ____________________ ____________________
____________________ ____________________ (___)_________ ____________________ ____________________
____________________ ____________________ (___)_________ ____________________ ____________________
____________________ ____________________ (___)_________ ____________________ ____________________
____________________ ____________________ (___)_________ ____________________ ____________________
18.
Attorney for firm
Name: __________________________________________________________________
Street Address: ___________________________________________________________
City: ___________________________ State: ________________ Zip Code: __________
10
Phone Number: (
19.
)_________________
C.P.A. or Accountant for firm
Name: __________________________________________________________________
Street Address: ___________________________________________________________
City: ___________________________ State: ________________ Zip Code: __________
Phone Number: (
20a.
)_________________
Has the firm applied for certification as an M/WBE, or DBE with another governmental agency, department or authority?
 Yes  No
If Yes, complete the following:
Agency
Date
Contact Person
Phone
Specify
M/W/DBE
1. Pending with
20b.
__________________________
_____________ ____________________ (
)_______
____________
__________________________
_____________ ____________________ (
)_______
____________
__________________________
2. Certified by
_____________ ____________________ (
)_______
____________
__________________________
_____________ ____________________ (
)_______
____________
__________________________
_____________ ____________________ (
)_______
____________
__________________________
3. Registered by
_____________ ____________________ (
)_______
____________
__________________________
_____________ ____________________ (
)_______
____________
__________________________
4. Withdrawn/Closed Out
_____________ ____________________ (
)_______
____________
__________________________
5. Rejected by
_____________ ____________________ (
)_______
____________
__________________________
6. Denied by
_____________ ____________________ (
)_______
____________
__________________________
7. Decertified by
_____________ ____________________ (
)_______
____________
__________________________
_____________ ____________________ (
)_______
____________
Are there appeals pending on any of the above applications or certifications?
Agency
 Yes
 No
Date of Appeal
Contact Person
Phone
__________________________________
____________
_____________________________ (
)
__________________________________
____________
_____________________________ (
)
__________________________________
____________
11
_____________________________ (
)
__________________________________
21.
22.
____________
_____________________________ (
)
List the three largest accounts for which the applicant has provided goods or services within the last two years:
Firm Name & Phone
Account
Dollar
Amount
Location of
Performance
Duration
_________________________________
_________________
__________________________
________
_________________________________
_________________
__________________________
________
_________________________________
_________________
__________________________
________
_________________________________
_________________
__________________________
________
Identify Bank(s) where firm’s accounts are maintained.
Bank Name
Address
Contact
Type of Account Account No.
____________________ ____________________ ___________________________ _____________ ____________
____________________ ____________________ ___________________________ _____________ ____________
____________________ ____________________ ___________________________ _____________ ____________
23.
24.
25.
Do you have a line of Credit?
 Yes
 No
If Yes, Identify
Source
Limit
Name of Guarantor(s)
__________________________________
____________
________________________________________________
__________________________________
____________
________________________________________________
__________________________________
____________
________________________________________________
List major current creditors and/or lenders and types of investment and/or loans in the firm.
Name of
creditor/lender
Type of investment/
credit/loan
Dollar value of investment/
terms/credit/loan
__________________________________
__________________________________
___________________________
__________________________________
__________________________________
___________________________
__________________________________
__________________________________
___________________________
__________________________________
__________________________________
___________________________
If your company is owned in full or in part by another firm, please identify the firm and the percentage of ownership
interest. Include venture capitalists and other similar investors.
Firm Name
Address
Percentage Ownership
__________________________________
__________________________________________ ____________________
__________________________________
__________________________________________ ____________________
__________________________________
__________________________________________ ____________________
12

 Yes
Is the firm bonded? If yes, specify type and limit.
 No
Bonding Company _______________________________________Type_____________________Limit_______________
Address ____________________________________________________________________________________________
Telephone (_____)_______________
Contact Person __________________________________________________
13
SUPPORTING DOCUMENTS
A. REQUIRED FOR ALL APPLICANTS.
Attach copies of the following, if applicable. Please indicate documents submitted by checking appropriate boxes.
NOTE: If appropriate documents are not submitted AND no written explanation is given, application will be returned to you.

1. Resumes of all principals, partners, officers and/or key employees of the firm as per 8(e), 10(a) and 15(a). Show
home address and telephone number, education, training and employment with dates.

2. Bank signature card, bank resolution, or letter from the bank identifying persons authorized to conduct
transactions, level or authority and limitations, if any.

3.
Current financial statement.

4.
Most recent three years’ Federal (corporate and personal) tax returns including all schedules, where applicable.

5.
Proof of sources of capitalization/investments.

6.
Proof of ethnicity (i.e., Birth Certificate, Baptismal Certificate, U.S. Passport, etc.)

7. Proof of U.S. Citizenship (i.e., Birth Certificate, Baptismal Certificate, U.S. Passport, Naturalization Certificate,
etc.)

8.
Proof of permanent resident alien status, i.e., permanent resident (“green”) card.

9.
Lease Agreements per 16(a) and 16(b) for business premises.

10. All third party agreements including: equipment rental, purchase agreements, management service agreements,
etc.

11. Any employment agreements

12. Vehicle registration(s).

13. Any certification, decertification or denial of certification documentation.

14. Proof of Small Business Administration 8(a) Certification (copy of all approval letters).

15. Written request for exemption from disclosure regarding trade secrets.
B. REQUIRED FOR A SOLE PROPRIETORSHIP
(Attach copies of the following: Please indicate documents submitted by checking appropriate boxes.)

1. Copy of Certificate of Trade Name or Business Trade Name filed with County Clerk (if doing business under an
assumed name).
C. REQUIRED FOR A PARTNERSHIP AND A JOINT VENTURE PARTNERSHIP
(Attach copies of the following: Please indicate documents submitted by checking appropriate boxes.)

1.
Business Certificate

2.
Partnership agreement

3.
Buy-out Rights
14
D. REQUIRED FOR A CORPORATION
(Attach copies of the following: Please indicate documents submitted by checking appropriate boxes.)

1.
Articles of incorporation, including date approved by State

2.
Corporation By-Laws

3.
Minutes of first corporate organizational meeting and amendments.

4.
Copies of all issued stock certificates, front and back, as well as next, unissued certificate.

5.
Copy of stock ledger.

6.
If applicable, furnish copies of agreements relating to;
o stock options
o shareholder agreements
o shareholder voting rights
o restriction on the disposal of stock loan agreements
o facts pertaining to the value of shares
o buy-out rights
o restrictions on the control of the corporation

7.
List of current Board of Directors including group code, sex and effective dates.
Group
Code
Name
Position
___________________________
___________________________ ______  Male  Female
___________
___________________________
___________________________ ______  Male  Female
___________
___________________________
___________________________ ______  Male  Female
___________
___________________________
___________________________ ______  Male  Female
___________
___________________________
___________________________ ______  Male  Female
___________
___________________________
___________________________ ______  Male  Female
___________
15
Sex
Date
DEFINITIONS OF MBE, WBE AND DBE
(To be used to answer Question 5, Page 1)
MINORITY BUSINESS ENTERPRISE (MBE) - A business enterprise which is at least fifty-one percent (51%) owned by, or in the
case of a publicly owned business at least fifty-one percent (51%) of the stock of which is owned by citizens or permanent resident
aliens meeting the ethnic definition of:
01
02a
03a
03b
04
Black
Hispanic
Asian-Pacific
Asian-Indian
Native American
WOMEN-OWNED BUSINESS ENTERPRISE (WBE) - A business enterprise which is at least fifty-one percent (51%) owned by,
or in the case of a publicly owned business at least fifty-one percent (51%) of the stock of which is owned by citizens or permanent
resident aliens who are women.
DISADVANTAGED BUSINESS ENTERPRISE (DBE) - a small business concern which is at least fifty-one percent (51%) owned
and controlled by one or more socially and economically disadvantaged individuals or, in the case of a publicly owned business at
least fifty-one percent (51%) of the stock of which is owned by one or more socially and economically disadvantaged individuals;
and whose management and daily business operations is controlled by one or more such individuals.
“Socially and economically disadvantaged individuals” are individuals who are citizens or lawful permanent residents of the United
States and are:
01
02a
02b
02c
03a
03b
04
05
05a
Black
Hispanic
Portuguese
Spanish
Asian-Pacific
Asian-Indian
Native American
Residents of Public Housing
Low Income persons living in areas where a HUD-assisted project is located
Women, regardless of race or ethnicity
Members of other groups or other individuals found, on a case-by-case basis, to be economically and socially
disadvantaged by the U.S. Department of Transportation grant recipients or the Small Business Administration under
Section 8(a) of the Small Business Act, as amended (a5 U.S.C. 637)
UNDER EACH CERTIFICATION CATEGORY, OWNERSHIP MUST BE REAL, SUBSTANTIAL AND CONTINUING.
THE APPLICANT MUST HAVE AND EXERCISE THE AUTHORITY TO INDEPENDENTLY CONTROL THE
BUSINESS DECISIONS OF THE ENTERPRISE.
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FRAUD
The undersigned does hereby swear that the statements contained in this application and all attachments that have been provided in
support of this application (hereafter referred to as “this application”) are true, accurate, and complete and include all material
information necessary to identify and explain the ownership and operation of:
_____________________________________________________________________________________________________
(Insert Full Name of Applicant Company Here)
Further, the undersigned does covenant and agree to provide the Muskegon County Unified DBE Opportunity Advisory Committee
(hereafter referred to as the “DBOC”) with current, complete, and accurate information regarding this application, its attachments, or
any project or contract issued by its corporate members. The undersigned further agrees that, as part of this certification procedure,
DBOC may freely contact any person or organization named in this application to verify statements made in this application and/or
to secure additional information or data required to grant to, or withhold from, the applicant company certification as a Minority
Business Enterprise, a Women business Enterprise (or both) or a Disadvantaged Business Enterprise. The undersigned understands
and agrees that failure to submit required materials and/or to consent to interview(s), audit(s), and/or examination(s) will be grounds
for immediate rejection of this application for certification or recertification.
It is recognized and acknowledged that the statements contained in this application have been given under oath and that any material
misrepresentation will be grounds for denial or certification or for decertification and may result in not awarding or terminating
contracts which may be awarded as the result of information contained in this application.
The undersigned further acknowledges that information contained in this application may be shared with any public department,
agency, etc., which is responsible for providing funding used to fulfill contracts arising from the representations made in this
application. The release of such information will be subject to all laws of the State and Federal government applicable to the
treatment of confidential information and/or material.
It is further understood that certification as an MBE, WBE, M/WBE, or DBE will be suspended for a period of up to, but not
exceeding, two years if, after proper investigation by DBOC, the applicant is determined to be engaging in activities which
circumvent the intent of the Muskegon County Unified DBE Program.
The applicant further understands that misrepresentations made in this application are subject to all laws of the State of Michigan
which deal with civil and criminal fraud. Under these laws convictions may result in fines up to $100,000 (or any higher amount
equal to double the pecuniary gain to the offender or lost to the victim) or a jail term of between five and ten years.
The undersigned further acknowledges that certification is normally reviewed annually but that DBOC retains the right to reevaluate
the contents of this application at any time.
I have read and acknowledge the foregoing.
____________________________________________________
Signature of Applicant
Corporate Seal
(if applicable)
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VERIFICATION
(A)
______________________________, being duly sworn, states he or she is the owner of (or a partner
Name of Applicant
in) the enterprise making the foregoing Application and that the statements and representations made in the Application are
true to his or her own knowledge.
(B)
______________________________________, being duly sworn, states that he or she is the
Name of Corporate Officer
_________________________________________, of ______________________________________
Title of Corporate Officer
Name of Corporation
making the foregoing Application, that he or she has read the Application and knows its contents, that the statements and
representations made in the Application are true to his or her own knowledge, and that the Application is made at the
direction of the Board of Directors of the Corporation.
__________________________________________ __________________________________
Authorized Signature
Date
Sworn to before me this
_______ day of____________________, 20_____
__________________________________
Notary Public
Person assisting in completing the Application:
__________________________________
____________________________________________
__________________________________
Print Name
Signature
Telephone Number
NOTE: Applicant must also sign page 17
Mail Form to:
County of Muskegon Administration
Unified DBE Opportunity Advisory Committee
c/o Muskegon County Purchasing Department
141 E. Apple Avenue
Muskegon, MI 49442
PLEASE READ THIS ENTIRE ITEM CAREFULLY!!
Only the Signature of the owner of a sole proprietorship, a partner of a partnership or the president of a corporation is acceptable.
(For a partnership, only a General Partner may sign, the signature of a Limited Partner is not acceptable.) When completed, the
entire application must be notarized.
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