FORM 3 - DBE BUSINESS DATA SHEET.pdf

FORM 3 - BUSINESS DATA SHEET Page 1 of 2

TO BE COMPLETED BY PRIME AND ALL SUBCONTRACTORS IDENTIFIED AT ANY TIER ON THE

SUCONTRACTOR LISTING FORM OR FORM 1 AND ATTACHMENT A TO FORM 1

Part A: Business Data

1. Business Name: _______________________________________________________________________________________

2. Is your business a DBE? YES NO (If marked “DBE”, a copy of the certification letter for this business must be attached to this Form)

3.

a. If you answered yes to question 2, is your business currently a DBE certified by California Unified Certification Program (CUCP)? YES NO

b. Certified by an organization outside of California? YES NO

Name of Certifying Agency:__________________________________________

4. Is your business which will be performing the work on this Project a Joint Venture or participating in a Joint Venture for this Project?

(If answered YES, the Joint Venture Agreement must be submitted with the bid) YES NO

5. If you answered yes to question 4, provide the name of the Joint Venture (JV), the name of each Partner or Member of the Joint Venture, indicate whether the Joint Venture and each Partner or Member is a DBE, and the name of the Certifying Agency of the DBE Joint Venture and each Partner or Member as well as a copy of the certification letter.

a. Name of Joint Venture (JV): ________________________________________________

Business Name of JV Partner/Member: ______________________________________ DBE Non-DBE Name of Certifying Agency: ________________________________________________

Business Name of JV Partner/Member: ______________________________________ DBE Non-DBE Name of Certifying Agency: ________________________________________________

Business Name of JV Partner/Member: _______________________________________ DBE Non-DBE Name of Certifying Agency: ________________________________________________

5. Primary Business Address: _____________________________________________________________________________ (Street) (City) (State) (Zip)

6. Mailing Address: _____________________________________________________________________________________ (Street) (City) (State) (Zip)

7. County Business is located in: ___________________________________________________________________________

8. Name of Contact Person: ________________________________, _____________________________________________ (Name) (Title)

9. Owner’(s) Ethnicity: ___________________________________________________________________________________

10. Phone: ( ) _________ - ______________ 12. Email Address:________________________________

13. Fax: ( ) _________ - ______________ 14. Age of Business: ______ Years, and _______ Months

14. If your business requires a license, complete below. 16. Business Annual Gross Receipts:

a. License Type: __________________________ a. Less than $500,000

b. $500,000 to $1,000,000

b. License #: __________________________ c. $1,000,000 to $2,000,000

d. $2,000,000 to $5,000,000

c. Expiration: __________________________ e. $5,000,000 to $25,000,000

f. Over $25,000,000

FORM 3 - BUSINESS DATA SHEET (Continued) Page 2 of 2 Part B: Work Descriptions

18. Identify the scope of work and corresponding North American Industry Classification System (NAICS) Code(s) that will be performed by this business of the project that is the subject of the procurement.1

DESCRIPTION OF WORK OR SERVICE TO BE

PERFORMED, OR MATERIALS SUPPLIED ON THIS

CONTRACT

ONLY LIST APPLICABLE NAICS CODE(S) (6

DIGITS) LISTED WORK TO BE PERFORMED

19. Will your business provide trucking company services on this project? Yes No

If marked YES, please complete items a. to c. below. If answered NO, answer “Not Applicable.”

a. How many trucks does your company own? ____________________

b. How many trucks does your company lease? ____________________

c. How many trucks are registered to your company? ____________________

Part C: Signature

The undersigned Director, Officer, General Partner, or similarly situated Principal of the business declares he/she is informed and believes, and thereon attests, that to the best of its knowledge and information, that the information set forth on this page and any attachments, is current, complete and accurate.

Business Name:

Authorized Signature:

Printed Name:

Title:

Date:

1To receive credit, DBE firms must be certified in applicable NAICS Codes for listed scope of work.