Federal Requirements For Construction Contracts Page 19
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35MINORITY AND WOMEN OWNED BUSINESS ENTERPRISES
IDENTIFICATION STATEMENT
If applicable, this form is to be submitted by General Contractor, Consultant, or Service Provider
as part of the Contract or Agreement, and by Subcontractors before they begin work.
Name of Company/Organization:
Address of Company/Organization:
Company/Organization Telephone Number:
Tax Identification Number:
Name of Project:
1.
Indicate if, on this project, you are a
general contractor
subcontractor
Specify trade or service:
supplier/vendor
Specify product or service:
2.
When was the company/organization established?
3.
State the name of each owner of the enterprise, the minority group to which he/she
belongs (if applicable), his/her percentage of ownership, and his/her type of investment.
Minority
Type of Investment: (Check all that apply)
Group*(if
Percent
Name
applicable)
Ownership
Financial
Equipment
Management
Labor
None
*Female, African American, Hispanic, Native American, Asian/Pacific Islander, Eskimo/Aleut
4.
The above percentages of ownership have existed since
.
Page 17
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