About Certification

Many corporations, especially those in the National Minority Supplier Development Council Network, have special programs designed to assist minority owned firms to meet with their needs. In order to ensure that these programs are focused on those for whom they were intended, "Certification" was established a number of years ago.

In order to be certified as a bona fide Minority Business Enterprise (MBE), a firm must be:

Legally organized.

Established as a full-time, profit-making entity

At least 51% owned by a United States Citizen or a Naturalized Citizen who is African-American, Hispanic-American,Native-American, Asian-Pacific American or Asian-Indian American.

The minority group member(s)' ownership interest in the firm must be real, substantial and continuing.

Under the day-to-day control and guidance of a minority group member.

At its simplest, certification is a verification of statements that one is a minority, who owns and manages a firm. This

verification is established through a thorough examination of various documents, on-site visits and interviews. The

documents examined depend on the type of organization that the firm has adopted - sole proprietorship, partnership or

corporation.

See page 7 for Certification fees

GENERAL INSTRUCTIONS

In order to become a certified minority supplier of the New York & New Jersey Minority Supplier Development Council, Inc. (NY & NJ MSDC) certification is mandatory.

Please complete the application in its entirety and forward it to the Council office at the address listed below. Failure to comply may result in a rejection of your application.

The following information is required of all applicants for certification:

1. Answer all questions.

2. If a particular question does not apply to your business’ operation, please write "not applicable" in thespace provided.

3. Where more information is needed than the space permits, write, "see attachment" and attach theinformation to the application.

4. Complete the certification checklist before submitting the application.

All applicants must sign and date the affidavit at the bottom of the application. Certification with NY & NJ

MSDC is not automatic. It is your responsibility to comply with the requested information and documentation in a

prompt and timely manner.

Please return this application, documents, and non-refundable application-processing fee. A $40 returned check fee will be charged for any returned checks. Checks should be made payable to:

New York & New Jersey Minority Supplier Development Council, Inc. 320 W37th Street 9th Floor

New York, NY 10018

If you have any questions on any of the above, the content of this application; or the Regional Council in general, please call the certification department (212) 502-5663.

See page 7 for Certification fees

DR

New York & New Jersey Minority Supplier Development Council, Inc.

CERTIFICATION APPLICATION

General Instructions:

When answers require additional space, use plain white paper. Properly identify the item referred to by the appropriate number. At the top of each additional answer and exhibit, state the name of the applicant, date of the application and item number. Please answer all questions as completely as possible: if a particular question does not apply to your business operation, write “not applicable” (NA) in the space provided. You must include all attachments requested on page 8. Also the application must be signed, dated, notarized and include non-refundable fee SEE PAGE 7 FOR FEES

Date of application:_____/_____/_____(Day, Month, Year) D&B Number:_______________________

NAIC Codes: __________________________ 8a Certification Number:_____________________ (To find your NAIC Code please go to: www.census.gov. You must submit your NAIC code with your application to prevent rejection ) (NAICS CODES MUST BE 6 (SIX) DIGITS

BUSINESS INFORMATION

Name of Business

President President's Email address (required)

Business Street Address

City State Zip

Telephone Number Fax Number

Web site Address

Mailing Address (if different from Business Address)

City State Zip

Date Business Was Established:_____/_____/_____

Date of Acquisition (check one):

□ Bought existing business □ Started business □ Secured a franchise □ Merger or consolidation □ Other (please specify) ___________________________________________

Is your business a home-based operation? Yes_____ No_____

List or attach location of all additional facilities:

TO EXPEDITE CHECK THIS BOX □1

List all professional license(s):

Major Products and/or services offered:

Current Gross Annual Sales:____________________ Can you supply products or services: Local_____ Regional_____ National_____

Legal Structure (check one):

Number of Actual Employees: ______□ Proprietorship □ LLC□ Partnership □ LLP Total Number of Employees:__________ □ Corporation Total Number of Minority Employees:__________

Federal IRS ID Number:________________ ___________________________________________ ___________________________________________

Type of Business (check one): ___________________________________________ ___________________________________________

□ Manufacturing □ Construction ___________________________________________ □ Service □ Finance□ Professional Services □ Broker □ Other □ Transportation □ Distributorship

CUSTOMER BUSINESS REFERENCE

Customer Name

City State Zip

Buyer

Telephone Number Fax Number

Product/Service

Quality Approvals (if applicable)

Customer Name

City State Zip

Buyer

Telephone Number Fax Number

Product/Service

Quality Approvals (if applicable)

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Customer Name

City State Zip

Buyer

Telephone Number Fax Number

Product/Service

Quality Approvals (if applicable)

Customer Name

City State Zip

Buyer

Telephone Number Fax Number

Product/Service

Quality Approvals (if applicable)

BANK AND CREDIT REFERENCES

List Your Bank and Credit References:*

Name of Institution

Address

City State Zip

Type of Account Credit Line

Name of Bank Officer

Title Telephone Number

Name of Institution

Address

City State Zip

Type of Account Credit Line

Name of Bank Officer

Title Telephone Number

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List Other Credit References:

Name of Institution

Address

City State Zip

Type of Account Credit Line

Name of Bank Officer

Title Telephone Number*Note: Please submit copies of all existing banking resolutions along with signature cards.

CONSTRUCTION INFORMATION (if applicable)

Trade Specialty:_________________________ Bonding Capacity: _________________________

Bonding Agent:__________________________ *Please send copy of Bonding Certificate

Authorities/Licenses (list all professional licenses):

Union Name:____________________________ Union Affiliation:____________________________

Union Local:____________________________

Project Name:____________________________________ ___________________________________ (most recent) (largest)

Geographical Area:________________________________ ____________________________________

Start Date: _____/_____/_____ _____/_____/_____

Finish Date: _____/_____/_____ _____/_____/_____

Dollar Value: ____________________________________ ___________________________________

TRANSPORTATION INFORMATION (Transportation Carriers Only)

Operating Status: Independent Carrier_____ Common Carrier_____

List the Commodities You Normally Transport:

NY & NJ MSDC Certification Application, Page 5

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Operating Authorities: Interstate_____ Intrastate_____

Insurance Carrier:______________________________________________________________________ None: Please submit proof of insurance coverage.

List All Vehicles and Equipment:

Vehicles and Equipment* Owned/Leased? Registration Number

____________________ ____________ ____________________________ ____________________ ____________ ____________________________ ____________________ ____________ ____________________________ ____________________ ____________ ____________________________ ____________________ ____________ ____________________________

Please forward copies of all applicable vehicle title and/or lease agreements with this application.

PLANT INFORMATION

Plant Address

City State Zip

Program Manager Telephone Number

Facilities (Total Available Space) Office Square Feet

EQUIPMENT INFORMATION

List Your Basic Operating Equipment: Owned Leased

___________________________________ ______ ______ ___________________________________ ______ ______ ___________________________________ ______ ______ ___________________________________ ______ ______ ___________________________________ ______ ______ Please include a copy of Lease Agreement(s)

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MANAGEMENT INFORMATION

A. List the names of:

Each proprietor, partner, officer, director and stockholder. The names listed should include Minority Group Members and Non-Minority Group Members. Under ownership column note if S (stockholder, proprietor or partner), D (director) and/or O (officer).

B. Where the person is a minority group member, insert the appropriate code letter corresponding to the minority group in which he/she claims membership in accordance with the following:

Citizenship Status B = Black H = Hispanic E = Asian Pacific NA = Native American O = Other C = Caucasian X = Non-Minority AI = Asian Indian 1 = Birth 2 = Naturalized Citizen

Handles Ownership Daily Minority and Citizenship

Management Group Percent Status Name/Title Yes/No Member Ownership

________________________ __________ __________ __________ __________

________________________ __________ __________ __________ __________

________________________ __________ __________ __________ __________

________________________ __________ __________ __________ __________

________________________ __________ __________ __________ __________

C. Does the applicant business have any subsidiaries or affiliates or is it a subsidiary or affiliate of another concern? (Check one) □ Yes □ No If yes, provide the name, address, telephone number of the subsidiary, affiliate or parent. Also, describe the relationship of applicant company to the subsidiary, affiliate or parent.

D. Does applicant business concern or any person listed in Management Information (B) above have or intend to enter into any type of agreement with any other concern or person which relates to or affects the on-going administration, management or operations of the applicant concern? Such agreements include but are not limited to management and joint venture agreements and any arrangement or contract involving the provision of such compensated services as administrative services, marketing, production and other types of compensated services. If yes, attach a copy of any written agreement or an explanation of any oral or intended agreement.

E. Is the applicant business concern involved in any present of pending lawsuit? (Check one) □ Yes □ No If yes, provide details on a separate sheet.

F. Is the applicant business concern involved in bankruptcy or insolvency proceeding? (Check one) □ Yes □ No If yes, provide details on a separate sheet.

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G. Supply a copy of the applicant’s financial statement for one year preceding the year of application or for the time that the applicant has been in business if less than one year, plus financial statements of any subsidiaries or affiliates of the applicant for the same period of time. If the applicant is a new business concern a copy of an opening balance sheet and projection of income, or a statement by a certified public accountant which states that the applicant is a viable business concern. All financial statements submitted to the Council must show applicable date of information given and must be signed and dated by the proprietor, partner, or authorized officer unless prepared by an independent certified public accountant. All materials will be kept confidential.

H. Have you ever been rejected for certification by anyone? (Check one) □ Yes □ No If yes, state when, by whom and for what reasons:____________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Certification Fees

Annual Revenue_ Fee

Expedite Service(within ten (10) business days) $1000.00 (additional)

Class 1 Less than 1million $300Class 2 1 million - 10 million $500Class 3 10million - 50million $850Class 4 Greater than 50million $950

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CHECKLIST OF SUPPORTING DOCUMENTS

ALL 1. ____ Birth certificates or U.S. Passports for minority owners, directors, and key personnel.2. ____ Other proof of minority status of owners: tribal card, family genealogy3. ____ Current balance sheet and income statement.4. ____ Two (2) years of most recently filed federal tax return with all schedules and attachment. None exits.5. ____ If a new or start-up business-an opening balance sheet, projection of income, sources of capital, and target customers

and two (2) years of most recently filed personal federal tax return with all schedules and attachment.6. ____ Business loan agreements, promissory notes, and any debt instrument Include: repayment schedule, specified

interest rate, security or collateral given, maturity date, consideration paid or payable, promissory note. None exist.7. ____ Personal guarantees for any of the above. None exist.8. ____ Copies of all bank signature cards or Bank Resolutions9. ____ Lease agreements for all property and equipment. None exist.10. ____ Current resumes for all owners, director, offices, managers, and key personnel.11. ____ Any professional service, management, or joint ventures agreements. None exists.12. ____ Signed affidavit. (Page 9)13. ____ non-refundable processing fee made payable to the NY & NJ MSDC, Inc.14. ____Third-party agreements, such as rental and management service agreements

SOLE PROPRIETORSHIP

15. ____ Copy of Certificate of Trade Name or Business Trade Name. None exist.

PARTNERSHIP OR LIMITED LIABILITY PARTNERSHIP

16. ____ Business Certificate17. ____ Registration of LLP or RLLP. Not and LLOP or RLLP.18. ____ Partnership agreement and all amendments.19. ____ Buy-out rights.

LIMITED LIABILITY COMPANY

20. ____ LLC Certificate21. ____ Minutes of the annual and special meeting22. ____ Operating Agreement.23. ____ If out of state, authority to do business as a foreign LLC24. ____ Evidence of LLC interests (membership)

CORPORATION

25. ____All professional and business licenses(s) that are required to do business in state and city where the application ismade.

26. ____ Article of Incorporation and amendments including date approved by state or filing receipt.27. ____Minutes of the first and most recent Shareholders, Board of Directors and Corporate organization meetings28. ____Corporation By-Laws29. ____Both sides of all issued stock certificate(s) and the next consecutive un-issued certificate (not a specimen copy)30. ____Stock Transfer Ledger31. ____Proof of stock purchase32. ____If an out-of-state Corporation, copy of authority to do business in the state where application is made

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AFFIDAVIT OF APPLICANT Read the following paragraphs carefully! Your signature on this application indicates acceptance and understanding of the conditions.

A. OMISSION of information may be cause for this application not receiving timely and complete consideration. B. APPLICANT AGREES to allow the Council representatives access to and the right to a site visit of the applicant's place of

business. C. THE COUNCIL RESERVES THE RIGHT to request further information from the applicant prior to certification. D. APPLICANT AGREES to immediately notify the Council of all facts that would result in a failure to satisfy the requirements

contained in the guidelines. E. CERTIFICATION may be terminated at any time for good cause by the Council in accordance with the guidelines established by

the Council Board of Directors from time to time or for the best interests of the Council. F. ALL INFORMATION in this application is true and accurate and is submitted for consideration of certification and affiliate

membership. G. IF the Council discovers that a statement has been made herein which the applicant knows to be false, the certification process will

be terminated immediately. H. ALL MATERIALS submitted with this package shall become the property of the Council. I. DE-CERTIFICATION IS AUTOMATIC if a certified MBE has a change in ownership, control or management and does not

inform its home council within 30 days of said change. J. IF THE APPLICANT is awarded certification, the applicant agrees to abide by all rules governing their status as may be

determined by the Council Board of Directors from time to time.

The undersigned hereby swears under penalty of law that all statements made in this application are true.

The undersigned agrees to hold the Council harmless for any claim arising out of this application and agrees to indemnify the Council for any liability in connection with the certification of the applicant.

Business Name

Signature of Proprietor, all Partners, or President of corporation:

Signature Date Print Name

Signature Date Print Name

Signature Date Print Name

Signature Date Print Name

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The undersigned hereby declares (declare) under penalty of perjury that all statements made in this application and any attachments hereto and true and correct. I understand that the $200 Registration Fee is included and non-refundable

Business Name __________________________________________________________

Signature of all Proprietors, Partners and President of the Corporation

_____________________________________________ Date____________________

_______________________________________________ Date____________________

_______________________________________________ Date____________________

_______________________________________________ Date____________________

Please have this form NOTARIZED, retain a copy of this form for your files and return the original and the attachments to:

CERTIFICATION DEPARTMENT

NY & NJ MINORITY SUPPLIER DEVELOPMENT COUNCIL

320 W. 37th Street, 9th Floor New York, NY 10018 - 212 502-5663www.nynjmsdc.org

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State of _____________________________________________________________

County of____________________________________________________________

On__________________20___, before me, (name) _________________ the undersigned

Notary Public, personally appeared (name) ____________________________________, personally known to me, or proved to me on the basis of satisfactory evidence, to be the person(s) whose name (s) is/are subscribed to the within instrument, and acknowledged to met hat he/she they executed in the same in his/her their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s) of the entity upon which the person(s) acted, executed the instrument.

WITNESS my hand and official seal.

Notary Public____________________________________ ________________

(Seal)

Commission Expires_______________________________ _______________

NOTE: Public Law 99-272, the “Consolidated Omnibus Budget Reconciliation Act of 1985,” which amends Section 16 of the Small Business Act, establishes penalties of up to a $50,000 fine or imprisonment of up to five years, or both, for misrepresenting, in writing, the status of any concern or small business owned and controlled by socially and economically disadvantaged individuals (a “DBE”) in order to obtain for oneself or another any prime subcontract to be awarded as a result or in furtherance or any provision of federal law that specifically references Section 8(D) if the Small Business Act for a definition of eligibility.

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YEAR 2015 CERTIFICATION APPLICATION PAYMENT FORM (Please Print or attach business card)

Name:________________________________________________________________

Title:_________________________________________________________________

Company:_____________________________________________________________

Address:______________________________________________________________

______________________________________________________________________

Phone:___________________ Fax:________________ E mail_________________

Authorizing Signature___________________________________________________

PLEASE CIRCLE APPLICATION TYPE

(Please print clearly)

$_______________ Amount

Method of Payment: Please One:

Credit Card: (Amounts greater than $4000 are Subject to 3.25% fees for all credit card charg-es)

American Express

MasterCard

Visa

Discover

Card Number:____________________________________ Exp Date: ___________

Name on Card (please print)_____________________________ Title_________________

Authorizing Signature________________________________________________________

Phone ___________________ E-mail _________________________Date of Order____/____/____ ----------------------------------------------------------Special Instructions----------------------------------------------------

Use this area to let us know of any special invoicing procedures you would like us to honor.

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