Welcome:IMEC

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Welcome:IMEC


	May 2008

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Company Name:

Owner’s Name:

Owner's Email Address:

Owner's Telephone#:

Primary Contact Name:

Primary Telephone#:

Primary Email Address:

Business Address:

City:

Country:

State:

Zip:

Telephone#:

Fax#:

Email Address:

Website:

Ownership

Public Private

Year established:

Number of employees:

# of Minority Employees:

Brief description of goods and/or services provided:

Please mark all small business categories below that are applicable to your company.

Small Business

Minority Owned Small Business

Women Owned Small Business

Disadvantaged Business Enterprise (must be INDOT certified)

HUB Zone Small Business (must be SBA certified)

Veteran

Service Disabled Veteran

Minority Certifications held:

DBE MBE WBE SDBE

Minority Certifications needed:

DBE MBE WBE SDBE

Are you currently bonded?

Yes No

if yes what is the bond amount?
Name of Surety Bond Company:
Address of Surety Bond Company:
Contact Person's Name:
Telephone#:

Are you currently a union member :

Yes No

Trade designation:

Please read the following definitions carefully. If your company is a small business, it is extremely important that you classify your company accurately based on these definitions.

1.	A Small Business is one that is owned by a U.S. citizen(s) and that falls within the government’s size standards for small businesses.  The government’s

2.	A Minority Owned Business Enterprise (MBE) is a small business that is at least 51% owned by an individual(s) who is Black American, Hispanic American, Native American, Asian-Pacific American, or Sub-Continent-Asian American.

3.	A Women Owned Business Entity (WBE) is a small business that is at least 51% owned by one or more women, whose management and daily operations are controlled by one or more women.

4.	A Small Disadvantaged Business Entity (DBE) is a small business that is at least 51% owned by an individual(s) who the federal government considers to be socially and economically disadvantaged, that has its management and daily operation controlled by such an individual(s), and whose owner(s) net worth, excluding equity in the business and primary residence, does not exceed $750,000.  Black American, Hispanic American, Native American, Asian-Pacific American, or Subcontinent-Asian American as well as any others who believe they are socially and economically disadvantage may qualify.

5.	A HUBZone Small Business is a small business whose primary office is located in a Historically Underutilized Business Zone, and 35% of whose employees reside in the HUBZone. (The federal government requires that companies that represent themselves to be HUBZone small businesses be certified by the SBA).

6.	A Veteran-Owned Small Business is a small business that is at least 51% owned by one or more veterans or, in the case of any publicly owned business, not less than 51% of the stock of which is owned by one or more veterans and the management and daily business operations of which are controlled by one or more veterans.

7.	A Service-Disabled Veteran-Owned Small Business is a small business that is at least 51% owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51% of the stock of which is owned by one or more service-disabled veterans, and the management and daily business operations of which are controlled by one or more service-disabled veterans or in the case of a permanent and severe disability, the spouse or permanent caregiver of such veteran.

If you want more information on the aforementioned certifications and/or small business status criteria you may contact the following agencies at their respective websites.

◘ Small Business Administration (SBA) –

www.sba.gov

◘ Indiana Department of Administration (IDOA) –

www.in.gov/idoa.minority/index.html

◘ Indiana Department of Transportation (INDOT) –

www.indot.in.gov

◘ Historically Underutilized Business Zone (HUBZone) -

www.sba.gov/hubzone

01-30-2009	01-30-2009	01-30-2009	01-29-2009

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