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SAN FRANCISCO BAY AREA RAPID TRANSIT DISTRICT Office of Civil Rights 300 Lakeside Drive, Suite 1600 Oakland, California 94612

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SAN FRANCISCO BAY AREA RAPID TRANSIT DISTRICT Office of Civil Rights 300 Lakeside Drive, Suite 1600 Oakland, California 94612 SAN FRANCISCO BAY AREA RAPID TRANSIT DISTRICT Office of Civil Rights 300 Lakeside Drive, Suite 1600 Oakland, California 94612 FORM A – APPLICATION FOR CERTIFICATION AS A MINORITY OR WOMAN OWNED BUSINESS ENTERPRISE (M/WBE) FOR NON-DISCRIMINATION PROGRAM FOR SUBCONTRACTING INSTRUCTIONS: If you are currently certified as a minority or woman-owned DBE firm under the California Unified Certification Program (CUCP), submit Application Form A ONLY and a copy of the DBE Certification. Brokers and Manufacturers’ Representatives are not eligible for certification under this Program. All other firms, please complete entire application form along with the required supporting documents. 1. Name of Firm 2. Contact Person 3. Business Address (Post Office Box Unacceptable) City State Zip 4. Federal Tax Identification or Social Security Number 5. Telephone Number ( ) Fax Number ( ) 6. Email 7. Ownership Information A. Ethnicity and gender of majority owner *: B. List owners who have a 5% or more interest: U.S. Citizen/ Date of Vote Legal Resident Name Ethnicity * Gender Ownership Shares % (Yes/No) Check here ____ if more owners and continue on Item 13. Attach resumes for owners who have a 5% or more interest. C. Board of Directors: Name Title Ethnicity * Gender Term Check here ____ if more Board Members and continue on Item 13. * For ethnicity, fill in the Ethnic Code and where applicable, the description for the ethnicity: (Example: A - Chinese). AA (African American, i.e. persons having origins in any of the Black African racial groups); H (Hispanics; i.e. Cuban, Mexican, Puerto Rican, Latin American, European Spanish (but not Portuguese), and other Hispanic origins and cultures); A (Asians and other minorities (i.e. Asian and Pacific Islander, ancestral groups of Asian Indians, Chinese, Japanese, Filipino, Hawaiian and other Asian or Pacific Islander); NA (Native American ancestral groups of Aleut, Eskimo and American Indian); O (Other) _________________ (specify). M/WBE CERTIFICATION FORMS Revised, 2/15 PAGE 1 OF 9 D. Type of Ownership: Sole Proprietor _______ Partnership _______ Corporation ______ Joint Venture _______ Other Business Entity _______ State of Incorporation _______ E. Years in business: ____________________________ F. North American Industry Classification System Codes (NAICS) (Enclosed is a partial list of NAICS codes for your convenience. For a full list of NAICS codes and assistance in locating appropriate NAICS codes, please visit http://naics.com/search.htm.): Code 1: ___________________________ Code 4: ______________________________ Code 2: ___________________________ Code 5: ______________________________ Code 3: ___________________________ Code 6: ______________________________ 8. Indicate the nature of the firm’s business with a check: Construction __ Professional __ Other (Specify type of firm) ___________________________ 9. Is firm authorized to do business in the State of California? Yes _______ No _______ Please attach copies of the firm’s local business tax registration, business license, and permit to operate business and licenses such as a contractor’s license, architectural license or engineer’s license. 10. For all owners listed in Item 7B list the contributions of money, equipment, real estate, or expertise of each of the owners in Item 13. 11. Management: The following duties are actually performed by the persons indicated below: Preparation and presentation of Name Reports To estimates and bids: Hiring and firing management personnel: Purchasing or major equipment, materials and supplies: Financial Control: Negotiations and approval of contracts: Administration of company contracts: Supervision of field operations: Marketing and sales activities: 12. For each of those listed above, attach a brief summary of the person’s experience and number of years with firm, indicating the person’s qualifications for the responsibilities given him or her. 13. Identify any owner or management official of the named firm who is or has been an employee of another firm that has an ownership interest in or a present business relationship with the named firm. Present business relationships include shared space, equipment, financing or employees, as well as both firms having the same owners, describe in Item 13. 14. Additional information (attach additional pages, as necessary) The undersigned does hereby certify that the foregoing statements and attachments are true, accurate and complete and that all material information necessary to identify and determine the ownership and operation of the applicant firm has been included. The undersigned understands that if this application is accepted by the Office of Civil Rights, the firm will be eligible to receive credit as an M/WBE firm on BART’s non-federally funded contracts. Signature Title Print Name Date M/WBE CERTIFICATION FORMS Revised, 2/15 PAGE 2 OF 9 SAN FRANCISCO BAY AREA RAPID TRANSIT DISTRICT Office of Civil Rights 300 Lakeside Drive, Suite 1600 Oakland, California 94612 FORM-A CHECKLIST FOR DOCUMENTS SUBMITTAL ALL APPLICANTS 1. Proof of U.S. citizenship or lawfully admitted permanent resident for all owners and officers of your firm. 2. Proof of ethnicity for all minority owners and officers of your firm. 3. Work experience resumes (that include places of ownership/employment with corresponding dates), for all owners and officers of your firm. 4. Local business tax registration, business license, Fictitious Business Name Statement, and licenses such as a contractor’s license, architectural license, or engineer’s license. 5. Other documents as required. PARTNERSHIP OR JOINT VENTURE 1. Partnership agreement including the following major clauses: a) Buy out rights b) Profit sharing plan c) Capital contribution agreement 2. Other documents as required. CORPORATION 1. Articles of incorporation, By-laws, copies of stock certificates issued (not a specimen copy), proof of stock purchase and minutes of the following meetings: a) Organization meetings b) Shareholder meetings for the past 36 months c) Board of Directors’ meetings for the past 24 months 2. Copies of agreements related to: stock options, shareholder voting rights, ownership agreements, and ownership of voting securities, facts pertaining to the value of shares and restrictions on the disposal stock loan agreements.
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