Section 1 of 1 in this document

Minority Co-Developer Registration

Main Business Information

Business Legal Name

Doing-Business-As (DBA) Name (Complete if the business operates under a different name. The DBA must be legally registered.)

Current Business Structure

Business/General Partnership

Limited Liability Partnership (LLP)

Limited Partnership (LP)

Corporation

Limited Liability Company (LLO)

Date business was established under its current business structure (dd/mm/yy)

Main Telephone Number

Fax Number

Business Email Address

Business Website

Business Employer Identification Number (EIN)

Vendor Number

Authorized Representative

Business Title

Phone Number

Please Select how business originated or was acquired from the list below

Started the company

Bought an existing company

Inherited the company

Secured a franchise

Acquired the business via a merger or consolidation

What is your business's date of origination?(If acquired after origination,provide date of acquisition by current owner.)

Did the business exist under a different type of business structure, prior to the date its current business structure was established?If YES, please explain the history of business's structure

Has the business's Certificate of Incorporation, Business Certificate, or Certificate of Trade Name ever been amended? if Yes

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.

Full Name (First and Last)

Title/Postiion in Business

Position Effective Date (dd/mm/yy)

Business Finance Information

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)

Bank

Dollar Amount

Name of Source /Guarantor(s), if different from the bank

Business Operations Information

Please list the business' basic operating equipment.

Type of Equipment *

Acquisition(dd,mm,yy) *

Owned or Leased *

How did you first hear about the City of Newark's M/WBE certification program?(Select one)

Letter/Call/ Email from Department of Small Business Services

Leadership Association

Social Media

Advertisement, Publication

Is the business involved in the bidding process or contract/purchase order negotiations with any governmental agency, department, or authority?

YES

IF YES, check all that apply

Federal

State

City

Is this business bonded?

YES

If YES, please provide the following details

Surety Business

Name of Agent/Broker

Binder or Policy Number

Does the business have commercial or professional liability insurance?

YES

If YES, please provide details

Carrier Name

Dollar Amount of Liability Insurance

Is your business a signatory to union contract?

YES

If YES, please provide details

Union Name

Local Number

Please Provide a brief description of your business including the products or services it sells using appropriate keywords. (Maximum of 50 words)

Please identify your business market sector by selecting appropriate code(s) from the North American Industry Classification System(NAICS) https://www.census.gov/eos/www/naics/

NAICS Code

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.

NIGP Code

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.

Client's Phone Number

Date of Job

Name of Project

Description of Specific Tasks Performed (Explanation of work performed and results max. 50 words)

Dollar Value of Job received as payment by your business(Required and used to determine your business capacity)

Percentage of work Self Performed (The percentage of the work performed by your business)

Minority Co-Developer Registration

Main Business Information

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)

Full Name

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.)

Corporations Only: Please provide the following details about all current Officers and/or Board of Directors.

Business Finance Information

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)

Business Operations Information

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?

If YES, please provide details

Please identify your business market sector by selecting appropriate code(s) from the North American Industry Classification System(NAICS) https://www.census.gov/eos/www/naics/

Name of Client

Date of Job