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Lesbian, Gay, Bisexual, and Transgender Business Enterprise (LGBTBE®)

2014 CERTIFICATION APPLICATION

Please provide the following information. Unless otherwise indicated, all information is required in order to complete your company profile in the NGLCC/CVM Database. When answers require more space, attach additional paper and clearly identify the item by including the corresponding number. Please be sure to read the list of required documentation to ensure the submission of a complete application.

IMPORTANT NOTICE: Please submit only required documents in numerical order in accordance with the application. The submission of a well-organized application accompanied with the required documents will expedite the processing of your application. Please provide an explanation for any documentation you cannot provide. All supporting documentation will be kept confidential. Please note that the entire certification process, which includes a mandatory site visit[1], takes 60 to 90 days from the date your complete application is received.

Are you a member of the NGLCC or an NGLCC Affiliate Chamber of Commerce or Business Organization?

YesNoIf Yes, please list below:

Name of Affiliate/Business Organization CityState

Note: There is no fee associated with certification for applicants that are members of recognized NGLCC Affiliate Chambers. There is a $400 certification fee for applicants that are not members of their local affiliates. Please submit proof of current affiliate chamber membership in order to have the fee waived.

Date of Application:Amount Enclosed: $ Check #:

Name (as it appears on card)

Email Address:

Credit Card Type: American Express Master Card Visa Other:

Card #:Expiration Date:

Billing Address: Phone:

City: State: Zip:

SECTION I: General

General Company Information
Legal Business Name
Former Company Name(s)
Doing Business As
Where did you hear about us?
Company Website Address
Federal Tax ID
Legal Structure (Choose One) / S-Corp C-Corp LLC LLP Partnership Individual Proprietor
Business Acquisition / Bought Start Merger InheritedGifted Divestiture Other
Year Established
Year Company was Acquired by Owner (if applicable)
Gross Annual Sales for the last three (3) fiscal years / Year Revenue
1.
2.
3.
State of Incorporation
Number of Employees
Type of Industry
Headquarters Information
Street Address 1
Street Address 2
City, State, Postal Code
County
Phone
Fax
Mailing Address Information
Street Address 1
Street Address 2
City, State, Postal Code
County
Phone
Fax
Owner Contact (highest ranking LGBT owner)
Name
Street Address 1
Street Address 2
City, State, Postal Code
County
Phone
Fax
Email
Company Contact (person responsible for receiving communications from NGLCC)
Name
Street Address 1
Street Address 2
City, State, Postal Code
County
Phone
Fax
Email
Business Details
Business Controlled by a Trust / Yes No
If Yes, is it a: / Irrevocable Trust? Revocable Trust?
Is an LGBT Person a (check all that apply) / Benefactor of the Trust
Grantor of the Trust?
Trustee of the Trust?
If Applicant company is a contractor, please complete the following section:
License #
License Certification
Trade Specialty
Government Security Clearance
Does the company have a Government Security Clearance? / Yes No
Bond Details
Is the company Bonded / Yes No
If yes, Amount
Bonding/Security Company
If Applicant company involves Transportation, please complete the following section:
Operating Status / Common Carrier Independent Carrier
Common Carrier Operating Authorities / Interstate Intrastate
Insurance carrier
Commodities you normally Transport (List)
Is the Fleet / Contracted Leased Owned

SECTION II: Capabilities

Product / Service Information (You must enter at least one NAICS Commodity and SIC code)
NAICS Codes
(
SIC Codes
(
Specific Product(s)/Service(s) Description
(key words only; attach additional sheet if necessary)
Geographical Service Area / Local Regional National Global
If Local/Regional Please Specify Service Area

SECTION III: Diversity

Diversity Information: Check all that apply.
DISABLED (Disabled Person Owned) / MWBE (Minority Women Business Enterprise)
DBE (Disadvantaged Business Enterprise) / SBA 8(A) (SBA 8A Certified)
DBVE (DVBE) / SBE (Small Business Enterprise)
HBCU (Historically Black Colleges and Universities) / SDB (Small Disadvantaged Business)
HUBZONE (Hubzone) / VBE (Veteran and Vietnam Veteran)
LGBTBE (Lesbian Gay Bisexual Transgender Business Enterprise) / WBE (Women Owned Business Enterprise)
MBE (Minority Business Enterprise) / OTHER:

SECTION IV: REFERENCES

Leading Contracts: Three (3) leading contracts from the last fiscal year
These contacts should come from business with whom you have worked in the last 12 months and reflect the three largest contracts your business has held during that time.
Contract Reference #1
Company/Organization Name
Address
City, State, Postal Code
Buyer
Phone
Product/Service
Dollar Volume
Contract Reference #2
Company/Organization Name
Address
City, State, Postal Code
Buyer
Phone
Product/Service
Dollar Volume
Contract Reference #3
Company/Organization Name
Address
City, State, Postal Code
Buyer
Phone
Product/Service
Dollar Volume
Bank and Credit References (Please attach an additional sheet if necessary)—At least one reference required*
Identify the primary banking institution & contact that handles your business accounts as well as any institutions/contacts with which your firm has currently active loans or loans activated within three years prior to this application.
Institution Name
Address
City, State, Postal Code
Type of Account
Credit Line
Contact Name
Phone
Loan Date and Amount
Business References: Business references should be organizations, or individuals, with whom you have conducted business in the last 12 months that can attest to the quality of your product/service and your ability to deliver said products and services upon the agreed terms of the contract. These references can be clients, customers, or businesses with which you’ve partnered on projects or other contracts.
Business Reference #1
Business Name
Product/Service Provided
Contact Name
Phone
Email
Business Reference #2
Business Name
Product/Service Provided
Contact Name
Phone
Email
Business Reference #3
Business Name
Product/Service Provided
Contact Name
Phone
Email

SECTION V: Real Estate

Real Estate
Do you maintain a staffed, full-time office?
Is your main facility an office in the home?
List of Facilities
Please provide information about your company’s facilities. Information must be included for the Facility Type: Principal Place of Business. You may add information on additional facility types in a separate attachment to this application.
Type / Principal Place of Business
Address
City, State, Postal Code
Square Feet
Ownership
Rental Amount
Agreement? / Written Verbal
Shared? If so, with whom? / Yes No; If yes, please explain:

SECTION VI: Management

Management:
Provide the following information for each proprietor, partner, officer, directory, stockholder, and any other persons holding comparable authority. Authority is defined as Stockholder (stockholder, proprietor, partner or other equity owner), Director (director or person with comparable authority) and Officer (officer or person with comparable authority). The sum of % ownership represented should equal %100. Attach additional sheets if necessary.
Name
Title
Gender (Pronoun Preference) / Male Female Other (Specify)
% Ownership
Daily Management / Yes No
U.S. Citizen / Yes No
LGBT / Lesbian Gay Bisexual Transgender Not Applicable
Ethnicity / African-American Asian/Pacific Islander Caucasian Hispanic
Native American Other (specify):
When the company was started or acquired, what resources were contributed, by whom, and in what amounts?
Money:
Equipment:
Real Estate:
Other:
Who in your company:
  • Supervises day-to-day operations?
  • Supervises fieldwork (if any)?
  • Makes financial decisions?
  • Conducts marketing and sales?
  • Is responsible for signing contracts?
  • Selects projects on which to bid and accept?
  • Makes and approves major capital expenses?
  • Who actually does the bidding and estimating?

SECTION VII: Relationships

Business Relationships (attach additional pages if necessary).
Does the applicant have any subsidiaries/affiliates or is the applicant a subsidiary, affiliate or franchise? / Yes No
If yes, please provide the name and address of the business organization:
Business Name:
Street Address:
City/State/Postal Code:
Management Change
Does the applicant business or any person listed as Management in the “Management” section have or intend to enter into any type of agreement with any person or entity which relates to or affects the on-going administration, management or operations of the applicant? (Such agreements include, but are not limited to, management and joint venture agreements and any agreement or contract involving the position of compensated services such as administrative services, marketing, production and other types of services.) If yes, attach a copy of any written agreement or an explanation of any oral or implied agreement in the material that you send to your assigned partner organization. / Yes No

SECTION VIII: Additional Info

Additional Information
Is the applicant involved in any present or impending lawsuit? / Yes No
If Yes, please provide details in an attached document.
Is the applicant business involved in bankruptcy or insolvency proceedings? / Yes No
If Yes, please provide details in an attached document.
Have you ever been denied certification by anyone?
Yes No; If Yes, please provide the following information:
Denying Agency Date Denied Reasons

I (We) have completed and submitted the NGLCC Supplier Diversity Initiative Lesbian, Gay, Bisexual, Transgender (LGBT) Supplier Certification Application as requested by the National Gay & Lesbian Chamber of Commerce (NGLCC) and hereby certify that the information contained herein and on all attachments submitted are true, correct, and accurate to the best of my (our) knowledge and belief. I (We) understand that this Application for Certification and the criteria set forth have been developed according to the guidelines established by the NGLCC. The certification, when granted, will be for a one (1) year period. I (We) further understand that completion and submission of this form, together with all attachments hereto, is not necessarily the sole criteria for determining certification of LGBT status by the NGLCC.

I (We) acknowledge that if the NGLCC discovers that a statement has been made herein which the applicant knows to be false, the certification process will be terminated immediately and no refund will be given. I (We) agree that all materials submitted with this package shall become the property of the NGLCC.

I (We) further agree that once certified, the continued certification and registration by the NGLCC will be according to the guidelines, rules, and regulations of the NGLCC and may be amended from time to time. Termination of my (our) status may be based upon, but not necessarily limited to, any one of the following:

  1. Cessation of business operation by the LGBT business.
  2. Discovery that any false information was knowingly supplied to the NGLCC in the completion of this form or as contained in any attachments submitted.
  3. Failure to provide timely notice or withholding of any notice to the NGLCC of the transfer or loss of ownership and/or management and control of the business by its LGBT group member(s).
  4. Failure or refusal to allow the NGLCC and/or its representative access to the company’s place of business upon reasonable notice and demand for the purpose of a site visit.
  5. Sale, exchange, or transfer of ownership of the LGBT business, if such transfer results in the loss of control and ownership of the business by the LGBT group member(s).

I (We) understand and agree that the NGLCC reserves the right to request any additional information that it may deem necessary to substantiate the information and representations made by the applicant(s) for certification. I (We) declare that the company in whose name this application is being submitted is at least fifty-one percent (51%) owned by one or more LGBT individuals (as defined herein) and such individuals control, operate, and manage the company.

I (We) understand that my (our) company will be accessible by NGLCC corporate partners as well as published on at least an annual basis as an NGLCC LGBT certified supplier to the general public.

The NGLCC understands that the confidentiality of the information you provide in connection with your application for certification is of the highest importance. The NGLCC, the NGLCC Certification Committee members and Site Visitors hold this information in the strictest confidence and each member with access to your information has pledged not to disclose or disseminate that information unless ordered by a court of competent jurisdiction or the government.

The undersigned hereby agree(s) to hold the NGLCC free and harmless from any and all claims, demands, and damages whatsoever arising out of the presentation of this application and agrees to indemnify and hold the NGLCC harmless for any and all liability in connection with the certification of the information contained in this application.

The undersigned hereby declare(s) under penalty of perjury that all statements made in this application and any attachments hereto are true and correct. I (We) understand that the certification fee included is non-refundable. Recertificationis $200.00 and is assessed on an annual basis. Requirements for recertification are available from the NGLCC.

Business Name:

Signature(s) of Proprietor, all Partners or President of the Applicant Company:

Date:

Date:

Date:

Date:

Please have this form SIGNED and WITNESSED, retain a copy of this application for your files, and return the original completed application (including attachments) to:

Supplier Diversity Initiative

National Gay & Lesbian Chamber of Commerce

729 15th Street, NW, 9th Floor

Washington, DC 20005

On this day of , 20, before me appeared (name[s]) to me personally known, who being dully sworn, did execute the following affidavit, and did state that he or she was properly authorized by(name of firm) to execute the affidavit and did so as his or her free act deed.

WITNESS my hand.

Signed Name:

Commission Expires:

Public Law 99-272, the “Consolidated Omnibus Budget Reconciliation Act of 1985,” which amends Section 16 of the Small Business Act, established penalties of up to a $50,000 fine or imprisonment of up to five years, or both, for misrepresenting, in writing, the status of any concern or small business owned and controlled by socially and economically disadvantaged individuals (a “DBE”) in order to obtain for oneself or another any prime subcontract to be awarded as a result or in furtherance or any provision of federal law that specifically references Section 8(D) if the Small Business Act for a definition of eligibility.

Certifying LGBT Businesses. Connecting Our Communities.

729 15TH STREET NW, 9TH FL, WASHINGTON, DC 20005 P 202.234.9181 F 202.234.9185 nglcc.org

[1] In the event a site visit must be canceled or rescheduled due to business owner/principal schedules or lack of preparation on the part of the applicant business, an additional fee could be incurred which must be paid by the applicant business.