City Hall Rm 110
8:30 am to 5:00 pm
Current Business Structure
Date business was established under its current business structure (dd/mm/yy)
Business Address( Must represent physical location. Post Office Boxes are not accepted)
Business Mailing Address(Only complete if the business mailing address is different from the address provided)
Please Select how business originated or was acquired from the list below
What is your business's date of origination?(If acquired after origination,provide date of acquisition by current owner.)
For questions 18 & 19 ONLY, use the following codes to identify the ethnicity of each individual listed in your response.
B: Black H: Hispanic AP: Asian Pacific AI: Asian Indian N: Non-Minority
Corporations Only: Please provide the following details about all current Officers and/or Board of Directors.
Does the business have a Line of Credit? (DO Not provide your personal credit card information. Line of credit is the any credit source extended to your business by bank or financial institution)
Please list the business' basic operating equipment.
How did you first hear about the City of Newark's M/WBE certification program?(Select one)
Is the business involved in the bidding process or contract/purchase order negotiations with any governmental agency, department, or authority?
IF YES, check all that apply
Is this business bonded?
If YES, please provide the following details
Does the business have commercial or professional liability insurance?
If YES, please provide details
Is your business a signatory to union contract?
Please identify your business market sector by selecting appropriate code(s) from the North American Industry Classification System(NAICS)
Please identify your business products and services by selecting appropriate code(s) from the National Institute of Government
Purchasing (NIGP). (List one primary code and up to two additional codes. Please be as specific as possible, 5-digit codes are
preferred. Your selected codes should correspond to the contracts / jobs you list for this application. NIGP can be found online.
Please provide the three (3) most recent contracts/jobs your business has performed within the last two (2) years. (The jobs you list will be posted on our Online Directory of Certified Businesses as representation of your business’ work.)
Your client’s contact information will not be displayed on the Online Directory of Certified Businesses; it is only used for verification purposes. If your business has a client confidentiality policy and you are not able to disclose this information, please submit a notarized letter on your business’ letterhead explaining such policy. However, please be advised that the applicant firm must still provide this information.
Name of Client
Date of Job