Form Ioci 14-4 - Recognition Certification Affidavit - Business Enterprise Program Page 2
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3State of Illinois
Department of Central Management Services
BUSINESS ENTERPRISE PROGRAM
RECOGNITION CERTIFICATION AFFIDAVIT
Name of Firm:________________________________________________________________ FEIN #:____________________________
Address: ________________________________________________________________________________________________________
City: ______________________________________________________ State: ______________________ ZIP Code: _______________
Phone: ______________________________ Fax: ________________________________ Cell: ________________________________
Owner Name: ___________________________________________________ Title/Position:____________________________________
E-Mail:_________________________________________ Website URL: ___________________________________________________
1. Date the business was established: ______________
List the firm’s most recent annual gross sales: _______________
2. Certification status of applicant firm: CHECK ONE BOX ONLY
Minority Business Enterprise (MBE)
Female Business Enterprise (FBE)
Persons with Disabilities Business Enterprise (PBE)
Female-Minority-owned/controlled Business Enterprise (FMB)
3. Legal Structure (Check One):
Sole Proprietorship
Limited Liability Partnership
Partnership Limited
Liability Company
Corporation Limited
Liability Corporation
4. Entities with which your firm holds a current valid certificate. (Check All That Apply)
Submit the most current certificate or certification letter.
City of Chicago
Illinois Department of Transportation (IDOT)
Cook County
Chicago Transportation Authority (CTA)
PACE
Chicago Minority Business Development Council (CMBDC)
METRA
Women’s Business Development Center (WBDC)
5. List all Owners, Proprietors, Partners and Stockholders. Ethnic/Racial Groups Code: (B) Black/African Americans,
(H) Hispanic Americans, (NA) Native Americans, (AP) Asian-Pacific Americans, (AI) Asian-Indian Americans, and (W) White.
Ethnic
Date of
Owner Name
Title/Position
Gender
% of Ownership
Group
Ownership
6. Submit most recent Federal Income tax returns; include all attachments and schedules for the applicant firm.
7. Does your firm’s business require a professional licenses or licenses for any employee’s?
Yes
No
If Yes, please list the firm’s current local, county, and state business license(s), permits(s), and professional license(s).
(e.g., contractor, electrical, plumber, investment, architect or engineer’s) registration as required by law. Submit copies of any license
registrations, licenses, certificates or pending license applications obtained since your last State of Illinois BEP certification.
Name of Qualifying Individual/Firm
License Name
Expiration Date License Number
Any Limitations
This affidavit and supporting documentation should be delivered to the Illinois Department of Central Management Services,
Business Enterprise Program, 100 West Randolph Suite 4-100, Chicago Illinois 60601.
Page 2
IOCI 14-4
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