00 45 40 Verification of Business Status Minority and Women-Owned Business Certification.pdf

Vaults 60, 87 & ET Structural Repair and Grating Replacement

3930 VERIFICATION OF BUSINESS STAUS MINORITY AND

REVISED 03/06/25 WOMEN-OWNED BUSINESS CERTIFICATION

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DOCUMENT 00 45 40

VERIFICATION OF BUSINESS STATUS MINORITY AND

WOMEN-OWNED BUSINESS CERTIFICATION

General Contractor: Please answer all questions as completely as possible for your company. When answers require more space, use additional paper, properly identifying the item referred by appropriate number. If a particular question does not apply to your business operation, write not applicable (N/A) in the space provided.

General Contractors to supply Minority and Women owned Subcontractor and Supplier information. General Contractors do not need to supply Non-Minority and Non-Women owned Sub-Contractor and Supplier information.

1. Company Name:

2. Nature of Business:

3. Business Address:

4. City: 5. State: 6. Zip Code:

7. Email Address:

8. Website Address: 9. E-mail Address:

10. Employer’s ID Number/Federal ID Number:

11. Knox County Business License Number:

12. Type of Legal Business Structure:

☐ Corporation ☐ General Partnership ☐ Sole Proprietorship*

☐ Limited Liability Corporation or Company (LLC) ☐ Limited Liability Partnership (LLP)

*Definition of Sole Proprietorship is a company owned/operated 100 percent by one (1) individual or married couple. Split ownership does not constitute Sole Proprietorship.

13. Does your business qualify as a KUB-defined Small Business Enterprise (fifty or fewer employees and less than $10 million in annual revenue)?

☐ Yes ☐ No

VERIFICATION OF BUSINESS STAUS MINORITY AND 3930

WOMEN-OWNED BUSINESS CERTIFICATION REVISED 03/06/25

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14. Please list each owner (proprietor, partner, stockholder). The name listed should include Minority Group members and Non-Minority Group Members.

Name/Title Ethnic Origin* Gender Citizenship†

Ownership Percentage

(Entries Must Total 100%)

☐ M ☐ F ☐ 1 ☐ 2

☐ M ☐ F ☐ 1 ☐ 2

☐ M ☐ F ☐ 1 ☐ 2

*Ethnic Origin: A citizen of the United States who is:

a. White

b. African American

c. Asian

d. Hispanic

e. Native American.

*Asian Pacific whose origins who are in Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U.S. Trust Territory and the Pacific islands, the Northern Marinas islands, Laos, Kampuchea (Cambodia), Taiwan, Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Republic of the Marshall Islands, or the Federated States of Micronesia.

*Native American means American Indians, Eskimos, Aleuts, and native Hawaiians.

*Asian Indian Americans include United States citizens whose origins are from India, Pakistan, and Bangladesh.

†Citizenship Status – 1 = By Birth or 2 = Naturalized Citizen.

Declaration of Certification of Status: I have completed and submitted the Verification of Business Status Minority and Women Owned Business Certification requested by the Knoxville Utilities Board and hereby certify that the information contained herein, and any attachments submitted are true, correct, and accurate to the best of my knowledge and belief. I understand that this Declaration of Certification and the criteria set forth have been developed according to the definitions of minority and women owned businesses established by the Small Business Administration.

The undersigned hereby declares that all statements made in this application and any attachments hereto and true and correct.

CEO/President/Majority Owner Signature Date

3930 VERIFICATION OF BUSINESS STAUS MINORITY AND

REVISED 03/06/25 WOMEN-OWNED BUSINESS CERTIFICATION

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Will you have any Subcontractors? If yes, please provide:

1. $ Company Name Subcontracting for (List Trade, Type of Work) Approx. Dollar Value

Contact Name Phone Fax Fed ID #

E-mail ☐ Minority Owned ☐ Female Owned

2. $

3. $

Attach additional pages if more than three Subcontractors. END OF DOCUMENT