19-Vendors Participant List (Federal Funding).pdf

VENDOR’S PARTICIPANT LIST

The completed form should be returned with the Vendor’s submittal. Vendor should upload pdf file; do not scan or alter file format. If not provided with the submittal, Vendor must submit the form(s) within three business days after County’s request. Vendor may be deemed nonresponsive for failure to fully comply within the stated timeframe.

This solicitation is funded in part by federal assistance and is subject to the U.S. Department of Transportation's Disadvantaged Business Enterprise (DBE) or Airport Concession Disadvantage Business Enterprise (ACDBE) Program requirements. In accordance with federal law (49 C.F.R. §§ 26.11(c) and 23.27(c)), Broward County is required to establish and maintain a database of all firms participating or seeking to participate in federally assisted contracts funded by the U.S. Department of Transportation, including concession opportunities at the Fort Lauderdale- Hollywood International Airport (FLL).

The prime Vendor must complete Part A of the form. Part B must be completed for each subcontractor, subconsultant, sub-concessionaire, and goods and services provider that provided the prime Vendor with a bid/quote/proposal to perform work on the project.

Part A.

1. Federal Tax ID Number:

2. Firm Name:

3. Phone Number:

4. Address (street, city, state, zip):

5. Year Firm Established:

6. ☐ DBE ☐ Non-DBE OR ☐ ACDBE ☐ Non-ACDBE

7. Describe the type of work applicable to this contract that your company will perform and include applicable NAICS codes specific to this contract.

8. Contract Amount or Percentage:

9. Annual Gross Receipts:

☐ Less than $200,000

☐ $200,001 – $500,000

☐ $500,001 – less than $1 million

☐ $1 million – less than $5 million

☐ $5 million – less than $10 million

☐ $10 million – less than $20 million

☐ $20 million – less than $50 million

☐ $50 million – less than $100 million

☐ $100 million – less than $500 million

☐ $500 million – less than $1 billion

☐ $1 billion or more

10. Race and sex of the firm’s majority owner:

Sex: ☐ Male ☐ Female

Race:

☐ Black ☐ White ☐ Hispanic

☐ Asian Pacific☐ Native American ☐ Subcontinent Asian ☐ Other https://www.naics.com/search-naics-codes-by-industry/

(Continued) Part B. Subcontractor/Subconsultant Information

Provide this information for each subcontractor, subconsultant, sub-concessionaire, and goods and services provider that provided prime vendor with a bid/quote/proposal to perform work on the project.

1. Federal Tax ID Number:

2. Firm Name:

3. Phone Number:

4. Address (street, city, state, zip):

5. Year Firm Established:

6. ☐ DBE ☐ Non-DBE OR ☐ ACDBE ☐ Non-ACDBE

7. ☐ Subcontractor ☐ Subconsultant ☐ Trucking ☐ Regular Dealer ☐ Manufacturing ☐ Subconcessionaire ☐ Goods and/or services provider ☐ Other: _________________________

8. Describe the type of work applicable to this contract that your company will perform (please specify and include applicable NAICS codes):

9. Contract Amount or Percentage:

$___________________ or __________%

10. Annual Gross Receipts:

☐ Less than $200,000

☐ $200,001 – $500,000

☐ $500,001 – less than $1 million

☐ $1 million – less than $5 million

☐ $5 million – less than $10 million

☐ $10 million – less than $20 million

☐ $20 million – less than $50 million

☐ $50 million – less than $100 million

☐ $100 million – less than $500 million

☐ $500 million – less than $1 billion

☐ $1 billion or more

11. Race and sex of the firm’s majority owner:

☐ Male ☐ Female

Race:

☐ Black ☐ White ☐ Hispanic ☐ Asian Pacific Islander☐ Native American

☐ Subcontinent Asian ☐ Other:

Form Date: 7/17/2025

Sex:

https://www.naics.com/search-naics-codes-by-industry/

Accessibility Report

Filename:

Vendor's Participant List_DBE and ACDBE Program_1-17-25_fillable.pdf

Report created by:

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Summary

The checker found problems which may prevent the document from being fully accessible.

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Failed: 1

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