2-LCTA Bidders List Application.pdf

LUZERNE COUNTY TRANSPORTATION AUTHORITY

VENDOR PROFILE & BIDDERS LIST APPLICATION FORM

The U.S. Department of Transportation (DOT) (49 CFR 26.11) requires the Luzerne County Transportation Authority (LCTA) to obtain the following information from contractors and subcontractors who bid on LCTA federally-assisted contracts: Company name; company address;

status as a DBE or non-DBE firm; age of firm; and the annual gross receipts of the company. This information will be maintained in the LCTA vendor list. The purpose for maintaining a vendor list is to derive data on the relative availability of all firms and DBEs in the local market area. LCTA may also use this data in the future to help set overall DBE participation goals for LCTA federally-assisted contracts.

INSTRUCTIONS: This form must be completed by the general/prime contractor, each sub-contractor & joint venture partnership(s). Please provide copies of all business licenses, articles of incorporation, etc., and UCP, WBE, MBE and/or DBE Certifications with this form. Return this form to: Luzerne County Transportation Authority, attn. Finance Director/DBELO, 300 South Pennsylvania Ave., Wilkes-Barre, PA

18701-3303. Include the expiration date of any certifications and licenses listed. (All fields must be completed, please type or print legibly.)

APPLICATION SUBMISSION TYPE

This is the initial information entry for my business. Prime Contractor

This is an update to the existing information for my business. Sub-Contractor

CONTACT INFORMATION

Company Name Mailing Address

Telephone No. Fax No. City, State & Zip

Primary Contact Person & Title Website Address

Email Address Federal Tax Identification Number

Pennsylvania Business License Number Pennsylvania Contractor License Number (if applicable)

In what year was the company established?

COMPANY OWNERSHIP DECLARATION

Please list additional principals on a separate sheet of paper.

Name Title % Owned

Name Title % Owned

Name Title % Owned

SUPPLIER DEMOGRAPHICS

SUPPLIER DIVERSITY STATEMENT: Because LCTA receives federal funding, LCTA must report to the FTA all supplier outreach and diversity efforts. This information is used for reporting purposes only, and will not affect the ability of your firm to do business with LCTA. If you do not complete this section of the application, your firm will not be added to the LCTA vendor list. Minority-owned businesses (MBE) or Female-owned businesses (WBE) may qualify as a DBE by virtue of having 51% or more ownership status and active management in the day-to-day operations of the business. Information obtained is for statistical and reporting purposes only. Please designate the gender, ethnicity, and management arrangement of the majority ownership of your business. CHECK ALL THAT APPLY:

Male-Owned White/Caucasian Hispanic American

Female-Owned Asian American Pacific American

Veteran-Owned African American Other:

Disabled Veteran-Owned MBE – Enter Certification #:

Non-Profit Organization DBE – Enter Certification #:

Public Held Corporation SBE – Enter Certification #:

Private Owned Business WBE – Enter Certification #:

What is my firm’s current UCP certification status?

Yes, I am certified - Please provide documentation attached to this application.

No, I am not certified - To claim MBE, DBE, SBE or WBE status, official documentation is required.

Not Applicable.

If your firm is not UCP certified, do you want LCTA to provide your company with additional guidance on how to become certified? Yes No N/A

REGULATORY COMPLIANCE DISCLOSURE

DEBARRED STATEMENT: Has this firm or any of its principals ever been disbarred from providing any items or services by any local, state or federal government agency? Yes No

If yes, please attach a full detailed explanation, including dates, circumstances and current status.

DISCLOSURE STATEMENT: Has this firm or any principal, currently or previously, had any personal or business relationship with any member of the LCTA Board of Directors or LCTA employee, local, county, state or federal elected official or government employee, and/or member of Luzerne County Council? Yes No

If yes, please attach a full detailed explanation, including dates, circumstances and current status.

NET WORTH STATEMENT: Is the net worth of the 51% ownership of your business less than $1,320,000 on an individual basis (not counting the market value of their primary residence of their equity/investment in their business)?

Yes No

SMALL BUSINESS STATEMENT*: Are the annual gross receipts of your business (averaged over 3 years) less than

$23,980,000? Yes No

What are the annual gross receipts of your company? Check One:

Less than $1,000,000 $10,000,000 – $15,000,000

$1,000,000 – $5,000,000 $15,000,000 - $23,980,000

$5,000,000 – $10,000,000 Greater than $23,980,000

* The U.S. DOT annually decides on the amount of average annual gross receipts a firm must have to be eligible to become a certified DBE.

Currently, if your company in the previous three fiscal years has had average annual gross receipts below $23,980,000, your company may be eligible for DBE Certification.

SERVICES & COMMODITIES INFORMATION

Check all applicable items below for products and/or services your firm provides:

PROFESSIONAL SERVICES

Design Services and General Consulting Architectural & Engineering Services

Legal Services Advertising or Public Relations

Accounting or Auditing Consulting Financial Consulting & Actuarial Services Insurance Underwriting Services Computer and IT Services Training Other:

COMMODITIES

Office Supplies Vehicle Parts & Components Painting Supplies Fuels & Lubricants Computer & IT Equipment Janitorial Products Bottled Water Gases, Industrial Locks/Supplies Paper Products, Office Power Equipment Safety Equipment Tires/Tubes Tools (Hand/Power) Vehicles Radio Equipment First Aid Supplies Other:

CONSTRUCTION PROJECTS

Paving and Concrete General Contractor Excavating HVAC Systems Building Materials (Category): Other:

OTHER SERVICES

Component Rebuilding Printing Landscaping Cleaning & Custodial Vehicle Support/Towing Vehicle Maintenance Drug Testing Alarm Monitoring Carpet Cleaning Telecommunications Equipment Fire Systems Maint./Insp. Pest Control Other: Sub-Contract: Lease:

PRIMARY INDUSTRY CLASSISFICATION

The 2012 NAICS is described in the United States North American Industry Classification Manual, which is available on the internet at the U.S.

Census Bureau Web site: http://www.census.gov/eos/www/naics/.

A. List the most current and specific (2012) North American Industry Classification System (NAICS) designation code(s) which best describes the primary business of the firm (DBE and Non-DBE Firms):

B. List the certified (NAICS) designation code(s) assigned to the DBE firm by the UCP which best correlates to the firm’s primary area of work in furnishing goods and/or services to LCTA (DBE Firms Only):

SIGNATURE AUTHORIZATION

The undersigned hereby affirms that he/she is empowered to sign this form and affirms that, to the best of his/her knowledge, the information contained in this application is current and accurate.

Printed Name & Title:

Signature: Date:

Disclaimer: By submitting this application, I certify that this information is correct and that neither I or any person(s) in any connection with me as principal or officer, so far as is known, is now debarred or otherwise declared ineligible by any agency of the federal government from bidding for furnishing equipment, materials, supplies, or services. By submitting this form you acknowledge that you have read and understand our Privacy Policy and Terms of Use available at www.lctabus.com. The completion of this application is not a guarantee of award for any contact or contractual obligation, expressed or implied.

LCTA operates its programs and services without regard to race, color and/or national origin in accordance with Title VI of the

Civil Rights Act.

--- FOR LCTA USE ONLY ---

Date Received: DBELO Signature:

Rev: 08/2025