Exhibit B _ Certificate of Minority Form.docx

This document is a Certificate of Insurance and Minority Status form for Gordon State College's Procurement Project PPV-89-1201, specifically related to a Student Activity and Recreation Center. The form is designed for an applying firm to provide details about their professional liability insurance coverage and minority business status, with designated spaces to indicate the type of minority-owned business enterprise (MBE or WBE) for both the applying firm and any associated firms.

The form requires detailed insurance information including the name and address of the professional liability insurance carrier, the total coverage amount, and the per-claim deductible. Additionally, the document includes a notarization section for the applicant to formally attest to the provided information, with space for the notary public's signature, seal, and commission expiration date. While the specific insurance amounts and minority status are left blank in this template, the form suggests Gordon State College is seeking to ensure vendor diversity and appropriate insurance protections for the Student Activity and Recreation Center project.