Cal. Code Regs. Tit. 2, div. 2, ch. 4, subch. 4, art. 4, app A
This is the official application form for certification as a "Target Business Enterprise" with the Office of the State Treasurer of the State of California. Under the regulations adopted by the State Treasurer, a "Target Business Enterprise" includes all minority business enterprises (MBEs), women-owned business enterprises (WBEs) and disabled veteran business enterprises (DVBEs).
Instructions: Please review the applicable statutes and regulations. Answer all questions carefully. If a question does not apply to your firm or circumstances, please enter "NA."
___________________________
1. Name of Firm
Home Office Address __________(No.) ______________________________(Street) _____________________________________________(City) _______________(State) _______________(Zip)
Telephone Number(s) ________________________________________(Area Code and No.) ______________________________(Telefax No.)
California address (if different) __________________________________________________(Number) ______________________________________________________________________(Street)
__________________________________________________(City) __________________________________________________(Zip)
California Telephone Number(s) __________________________________________________(Area Code and No.) __________________________________________________(Telefax No.)
2. Name of Firm President/ Chief Executive Officer/ Managing Partner.
______________________________(First Name) _______________(M.I.) __________________________________________________(Last Name) ____________________(Title)
3. Name and title of person completing this application.
______________________________(First Name) _______________(M.I.) __________________________________________________(Last Name) ____________________(Title)
4. This firm is applying for certified status as (check all that apply):
__________ Minority-owned Business (MBE).
__________ Women-owned Business (WBE).
__________ Disabled Veteran-owned Business (DVBE).
5. For MBE Applicants Only.
(a) Please indicate the ethnicity of the firm's Principal Owner(s). (check all that apply):
| ___________________________ | American Indian/Native American | ___________________________ | Filipino | |
| ___________________________ | Asian | ___________________________ | Hispanic | |
| ___________________________ | Black/African-American | ___________________________ | Other (specify)___________________________ |
(b) Please indicate the percentage of the firm's stock or partnership interest owned by each of the ethnic groups identified as Principal Owners in Question 5 (a), above:
| ___________________________ | % | American Indian/ Native American | ||
| ___________________________ | % | Black/ African American | ||
| ___________________________ | % | Hispanic | ||
| ___________________________ | % | Asian | ||
| ___________________________ | % | Filipino | ||
| ___________________________ | % | Other (specify)___________________________ |
(c) Is the management and control of the daily operations of the firm in accordance with the division of ownership/partnership interests as specified in (b)?
___ Yes
___ No (Please explain).
___________________________
___________________________
6. For WBE Applicants Only.
(a) Please indicate the percentage of the firm's stock or partnership interest owned by the following:
___ % -- Female Ownership/Partnership.
___ % -- Male Ownership/Partnership.
(b) Is the management and control of the daily operations of the firm in accordance with the division of ownership/partnership interests as specified in (a) ?
___ Yes
___ No (Please explain).
___________________________
___________________________
7. For DVBE Applicants Only
(a) Are the owner(s) of this firm resident(s) of the State of California?
| ___________________________ | Yes | ___________________________ | No |
(b) Do the owner(s) of this firm have a disability rating as issued by either the U.S. Department of Veterans Affairs or the Department of Defense?
| ___________________________ | Yes** | ___________________________ | No | |
| ** | If yes, please attach award letter from the federal agency indicating the existence of a service-connected disability at the time this application is submitted to the Office of the State Treasurer. | |||
(c) Please indicate the percentage of the firm's stock or partnership interest owned by the disabled veteran owner(s).
___ % Ownership/Partnership
(d) Are the management and control of the daily operations of the firm in accordance with the division of ownership/partnership interests as indicated in Question 7 (c), above?
___ Yes
___ No (please explain).
___________________________
___________________________
8. Identify the specific type(s) of Professional Bond Services that the firm provides (check all that apply):
| ___________________________ | Underwriting | ___________________________ | Bond Counsel | |
| ___________________________ | Financial Advisor | ___________________________ | Underwriter's Counsel | |
| ___________________________ | Investment Advisor | ___________________________ | Other (please provide specific description below) |
___________________________
9. If licensing or accreditation is required to conduct the firm's business, please complete this item:
| Type of License/ Accreditation | Issued By | Date Issued | Expiration Date | Holder/Registrant of License |
| ___________________________________________________________________________________________ | ||||
| ___________________________________________________________________________________________ | ||||
| ___________________________________________________________________________________________ | ||||
| ___________________________________________________________________________________________ | ||||
10. Certification Eligibility.
(a) If your firm seeks certification as a "minority business enterprise," by submitting this application you certify that your firm qualifies under the following statutory definition:
"Minority business enterprise" means a business concern that meets all of the following requirements:
(1) A sole proprietorship owned by a minority or a firm or partnership, 51 percent of the stock or partnership interests of which are owned by one or more minorities.
(2) Managed by, and the daily business operations are controlled by, one or more minorities.
(3) A sole proprietorship, corporation, or partnership with its home office located in the United States, which is not a branch or subsidiary of a foreign corporation, firm, or other business.
(b) If your firm seeks certification as a "women business enterprise," by submitting this application you certify that your firm qualifies under the following statutory definition:
"Women business enterprise" means a business concern that is all of the following:
(1) A sole proprietorship owned by a woman or a firm or partnership, 51 percent of the stock or partnership interests of which are owned by one or more women.
(2) Managed by, and the daily business operations are controlled by, one or more women.
(3) A sole proprietorship, corporation or partnership with its home office located in the United States, which is not a branch or subsidiary of a foreign corporation, firm, or other business.
(c) If your firm seeks certification as a "disabled veteran business enterprise," by submitting this application you certify that your firm qualifies under the following statutory definition:
"Disabled veteran business enterprise" means a business concern that meets all of the following requirements:
(1) A sole proprietorship owned by a disabled veteran, or a firm or partnership, 100 percent of the stock or partnership interests of which are owned by one or more disabled veterans.
(2) Managed by, and the daily business operations are controlled by, one or more disabled veterans.
(3) A sole proprietorship, corporation, or partnership with its home office located in the United States, which is not a branch or subsidiary of a foreign corporation, firm, or other business.
11. Fraudulent Representations, Acknowledgements and Verification.
(a) In accordance with Section 16857 of the Government Code, a person or firm that willfully and knowingly makes any false statements or misrepresentations in an Application for certification as a Minority Business Enterprise or Women Business Enterprise shall be liable for:
(1) Civil penalty not to exceed $5,000 (for the first violation) and up to $20,000 for each additional or subsequent violation; and
(2) Suspension from bidding on, or participating as either a contractor or subcontractor in, any professional bond services contract awarded by the state for a period of not less than 30 days nor more than one year. For an additional or subsequent violation of this section, the period of suspension shall be extended for a period of three years. A person or firm that fails to satisfy any of the penalties imposed for violations of this section shall be prohibited from further contracting with the state until all penalties are satisfied.
THIS SUBSECTION DOES NOT APPLY TO APPLICANTS OR APPLICATIONS FILED WITH THE TREASURER FOR CERTIFICATION AS A DISABLED VETERAN BUSINESS ENTERPRISE. HOWEVER, IN ADDITION TO ANY CRIMINAL PENALTIES PROVIDED FOR BY LAW, THE MAKING OF ANY FALSE STATEMENTS OR MISREPRESENTATIONS IN AN APPLICATION FOR CERTIFICATION AS A DISABLED VETERAN BUSINESS ENTERPRISE WILL BE GROUNDS FOR TERMINATING ANY CONTRACTS AWARDED TO THAT APPLICANT BY THE TREASURER AND MAY RESULT IN THAT APPLICANT'S DISQUALIFICATION FROM PARTICIPATING IN FUTURE CONTRACTS AWARDED BY THE TREASURER.
(b) Applicant agrees to submit additional information upon request of the Treasurer and acknowledges that the Treasurer may deny the application for certification from an Applicant as a Target Business Enterprise (MBE, WBE, or DVBE) if the additional information is not submitted in writing within 30 days after it is requested by the Treasurer.
(c) The Applicant consents to inspection of its books, records and other relevant business documents and to interviews of its principals and employees by the Treasurer or the Treasurer's representatives for the purpose of determining whether the Applicant is, or continues to be, an eligible TBE. The Applicant acknowledges that its application may be immediately denied or certification revoked if such inspection or interviews are refused or if the Treasurer determines, as a result of the inspection or interviews, that the Applicant does not qualify as a TBE.
(d) The Applicant agrees to provide to the Treasurer (with or without prior request of the Treasurer) information regarding any change in ownership or management and control of the Applicant's business within 30 days of the effective date of such change.
AFFIDAVIT
The Applicant has caused this application to be signed on its behalf by the undersigned, thereunto duly authorized.
| ___________________________ | ||
| Applicant | ||
| By | ___________________________ | |
| ___________________________ | ||
| Title |
I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this application and the exhibits thereto and know the contents thereof, and that the statements therein are true and correct.
Executed at ______________________________(Place), on ____________________(Date), 19___.
________________________________________
(Signature)
NOTARY
On this ___ day of ______________________________ 19 ___, before me appeared ________________________________________(Name) to me personally known, who being sworn, did execute the foregoing affidavit, and did state that he/she was properly authorized by ____________________________________________________________(Name of Firm) to execute the affidavit and did so as his/her free act and deed.
SEAL
NOTARY PUBLIC ______________________________
COMMISSION EXPIRES ______________________________
Mail completed application to:
TBE Program
Trust Services Division
State Treasurer's Office
P.O. Box 942809
Sacramento, CA 94209-0001
Cal. Code Regs. Tit. 2, div. 2, ch. 4, subch. 4, art. 4, app A