MBE Application

Business Information
Company:
Parent Company:
Street Address:
 
City:
State / Zip:   /  
 
Mailing Address:
 
City:
State / Zip:   /  
Company Telephone Number:   Ext.
Company Fax Number:
Company Website (URL):
Company E-Mail Address:  
Federal Tax ID Number:   (SSN if Sole Proprietorship)
In the space below, please give a concise description of company's product(s), service(s), or type of construction. If your company offers more then one product/service, list primary product or service first. The description below will be placed in our database and online directory.  (up to 500 characters)
List owner, members, corporate shareholders and Limited Liability Corporation members and title:
Owner's Name   Owner's Title
 
 
 
Key Contact's Name:
Contact's Email:  
Title:
Select NAICS Code(s)
To remove items from the list above, highlight the NAICS code and click Remove From List button.
Type of Business: Check primary function. Check all that apply
Type of Legal Business Structure:
Date Business was Established:   (MM/DD/YYYY)

Certification
Is your firm, branch or subsidiary currently certified by other NMSDC affiliate council?
Name of Council:   Date:   (MM/DD/YYYY)
Has your firm ever applied for certification before?
By whom:   Date:   (MM/DD/YYYY)
Does your firm hold 8(a) certification:
What are the gross receipts of your firm for each of the past four years? Numbers only, no comma or decimal point (e.g., 3000000).
2007
2006
2005
2004
DUN and Bradstreet Number:
Number of Employees: Full Time:   Part Time: 
Number of Minority Employees:

Company Acquisition
Types of Acquisition:
Date of Acquisition:   (MM/DD/YYYY)

Company Figureheads
Please list each owner, proprietor, partner, officer, member, director and stockholder. The name listed should include Minority Group Members and Non-Minority Group Members. NMSDC does not certify non-citizens.
Figurehead 1
Name Years of Ownership Ownership Percentage Ethnic Origin
Title Ownership Role Voting Percentage Citizenship

Figurehead 2
Name Years of Ownership Ownership Percentage Ethnic Origin
Title Ownership Role Voting Percentage Citizenship

Figurehead 3
Name Years of Ownership Ownership Percentage Ethnic Origin
Title Ownership Role Voting Percentage Citizenship

Figurehead 4
Name Years of Ownership Ownership Percentage Ethnic Origin
Title Ownership Role Voting Percentage Citizenship

Operation Information
Are the business premises:
List location of all additional facilities:
Geographical Service Area:

Owner Contributions
List of contributions of each of the owners.
Name Actual Money ($) Equipment Real Estate Expertise (years)

License/Permit
If license or permit is required to provide product or service, give information as follows: *
Name of License HolderType of License/PermitLicense Number
* This is to know if license or permit is owned by the minority applicant.
Does your company share any resources with any other firm or individual?
(office facilities, storage space, equipment, personnel, inventory, financing, etc.) If yes please identify and explain fully.

Personnel
Identify any owner, management official or employee of your company who is associated with any other business.
If yes, explain fully and identify the business person with whom you have an agreement and attach any written agreement and/or explain any oral or intended agreements.
Identify those individuals (owners, non-owners and key employees) who are responsible for the day-to-day operations and policy decision-making, including those with prime responsibilities for:
OperationNameTitleEthnicity
Estimating:
Financial decisions:
Marketing/sales:
Payroll:
Personnel management:
Purchasing on major items:
Signatory on major documents:
Supervision of Field Operations:
What jobs firm will undertake:

Bonding
Is the company bonded?
Amount: 
Bonding/Security Company:

Customer Reference
Provide three current customer references.
Company:
Address:
 
City:
State / Zip:   /  
Buyer:
Phone:   Ext.
Product/Service:
Dollar Volume:
 
Company:
Address:
 
City:
State / Zip:   /  
Buyer:
Phone:   Ext.
Product/Service:
Dollar Volume:
 
Company:
Address:
 
City:
State / Zip:   /  
Buyer:
Phone:   Ext.
Product/Service:
Dollar Volume:
 

Bank Reference
Provide two current bank references
Name of Bank Officer:
Title:
Name of Institution:
Address:
 
City:
State / Zip:   /  
Type of Account:
Credit Line:
 
Name of Bank Officer:
Title:
Name of Institution:
Address:
 
City:
State / Zip:   /  
Type of Account:
Credit Line:
 

Special Cases
If your company is a Distributor, please complete: Average Dollar Value of Inventory:
 
If your company is a Manufacturer, list basic equipment and indicate whether equipment is leased or owned.
Basic EquipmentLeased/Owned
 
If your company is a Contractor, please complete the following section:
License #:
License Certification:
Trade Specialty:
Union Name:
Union Local:
Union Affiliation:
Most Recent Project:
Project Name:
Start Date:   (MM/DD/YYYY)
Finish Date:   (MM/DD/YYYY)
Geographical Area:
Dollar Value:
Please name your responsible Managing Officer or responsible Managing Employee:

Major Equipment
Transportation Information:
Common Carrier Operating Authorities:
Insurance Carrier:
List the Commodities you normally transport:
Vehicles/EquipmentOwned/LeasedQuantityRegistration Number
Does the applicant business have any subsidiaries or affiliates or it is a subsidiary of another concern?
Does applicant business concern or any person listed above have or intend to enter into any type of agreement with any other concern or person which relates to or affects the on-going administration, management or operations of the applicant concern? Such agreements include but are not limited to management and joint venture agreements and any arrangement or contract involving the provision of such compensated services as administrative service, marketing, production and other type of compensated services. If yes, attach a copy of any written agreement of an explanation of any oral or intended agreement.
Is the applicant business an/or owner concern involved in any present or pending lawsuit?
How did you hear about Louisiana Minority Business Council?