Small Business Enterprise (Sbe) Certification Application
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4Texas Department of Transportation
Construction Division/BOP Section
th
125 E. 11
Street
Austin, TX 78701-2483
(512) 486-5530
Form 2062 (rev. 09/01)
SMALL BUSINESS ENTERPRISE (SBE) CERTIFICATION APPLICATION
RETURN TO ABOVE LISTED ADDRESS
INSTRUCTIONS: All questions must be answered and all information requested must be submitted. DO NOT LEAVE ANY SPACE BLANK;
ENTER “N/A” FOR NOT APPLICABLE. If your application is not legible, complete, signed, dated and notarized and accompanied by all required
documentation, your certification will be delayed. For assistance, call the above number.
1.
NAME AND ADDRESS (Company Name –-Mailing Address
2. PRIMARY OWNER (X appropriate box)
- Street Address(If different) - City-State-Zip Code)
CITIZENSHIP:
U. S. Citizen
Lawfully Admitted Permanent Resident
Other (explain):
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
(OPTIONAL: For Statistical Purposes Only)
African-American
Alaskan Native
GENDER
Telephone: __________________________
Hispanic
Asian American
Female
Native American
Asian Pacific
Male
Fax:
__________________________
Non-designated Group
3. PRIMARY OWNER (Name – Title – Telephone – Fax)
4. BUSINESS STRUCTURE:
Date__________________
Sole Proprietorship
Corporation
Limited Liability Partnership
Partnership
Limited Liability Corporation
5.
OWNERSHIP: (Provide information for all owners) For additional space, attach a continuation sheet in the format below:
Name (First, MI, Last)
Title
% of Ownership
Authorized Signature
______________________________________________
________________
____________
__________________________________________
______________________________________________
________________
____________
__________________________________________
______________________________________________
________________
____________
__________________________________________
6.
GROSS RECEIPTS AND EMPLOYMENT LEVELS: Beginning with the most recent year in which the business filed a federal
income tax return with the Internal Revenue Service (IRS) and going back three previous years, provide the gross receipts figures as
they were reported on the federal income tax returns. Also, provide the total number of employees that were reported at least once on
the business federal and state employer’s quarterly reports for each of the respective tax filing reporting periods.
GROSS RECEIPTS # OF EMPLOYEES
TAX FILING YEAR
GROSS RECEIPTS # OF EMPLOYEES
TAX FILING YEAR
(1)_______________
_______________
___________________
(3)______________
______________
___________________
(2) ______________
_______________
___________________
(4) ______________
______________
___________________
Business size will be determined by the Business Activity and Service listed on your firm’s tax return, Schedule C or Schedule K.
7. DOES YOUR COMPANY OWN MAJOR EQUIPMENT?
8.
PAYEE IDENTIFICATION NUMBER
Check the appropriate
:
YES
NO
type of Identification Number assigned to the business for tax
filing purposes and provide the number below:
DOES YOUR COMPANY HAVE LEASED EQUIPMENT?
FEDERAL IDENTIFICATION NUMBER
YES
NO
(Employee ID #):_____________________________
or
SOCIAL SECURITY NUMBER
List owned/leased equipment on separate sheet, by type and
(SSN):______________________
quantity.
9.
LIST ANY OTHER AGENCY CERTIFICATIONS THAT YOUR FIRM HAS RECEIVED:
10. LIST THE THREE (3) LARGEST CONTRACTS THAT YOUR FIRM HAS RECEIVED:
CONTACT
PHONE
TYPE OF
CONTRACT
AMOUNT
PERSON
NUMBER
WORK
DATE
__________________
_________
______________________
__________
__________________
________
_________________
_________
______________________
__________
__________________
________
__________________
_________
______________________
__________
__________________
________
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