Uniform Certification Application-annotated

more than 10 hours per week?

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uniform-certification-application 2.8.2021

Do any of your immediate family members, managers, or employees own, manage, or are associated with another company

more than 10 hours per week? If yes, identify this activity
(4)(a) What is the personal net worth of this disadvantaged owner applying for certification $
(b) Has any trust been created for the benefit of this disadvantaged owners
Yes
No
(If Yes, you maybe asked to provide a copy of the trust instrument).
(5)
Do any of your immediate family members, managers, or employees own,
manage, or are associated
with another company?
Yes
No If Yes, provide their name, relationship, company, type of business, and indicate whether they own or manage
(Please attach extra sheets, if needed)
:

US. DOT Uniform DBE / ACDBE Certification Application • Page 9 of 15
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