HomeMy WebLinkAboutregistration affidavit4.4. MINORITY/WOMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT
Please Check One Box Only [ 1 Hispanic [ ] Female Kgrack [ ] Not Applicable
If business is not 51% minority/female owned , affidavit does not apply. If not applicable, notarization is not required.
I (We), the undersigned agree to the following conditions:
1) that we have read Section 2.25 of the General Terms and meet the fifty-one percent (51%) ownership and management
requirement for minority/women registration status and will abide by all of the policies and regulations governing the City of
Miami Minority and Women Business Enterprise Procedures;
2) that if at any time information submitted by the undersigned applicant in his/her Bidder Application should prove to be false,
inaccurate, or misleading, applicant's name will be struck from the City of Miami's Master Bidder list with no further
consideration given to this applicant;
3) that the City of Miami maintains the right, through award of bid/contract, to revoke the award, should it be found that false,
inaccurate or misleading information or a change in the original information have occurred;
4) to notify the City of Miami within thirty (30) days of any change in the fumes ownership, control, management or status as an
ongoing minority/women business concern as indicated on the Bidder Application, and that the City of Miami, upon a finding
to the contrary, may render a firm's registration with the City null and void and cease to include that firm in its registered list
of minority and women -owned businesses;
5) that the City of Miami has a right to diligently verify all information submitted by applicant in his/her Bidder Application to
monitor the status of the Minority/Women Business Enterprise, once registered;
6) that the City of Miami may share a firm's registration information concerning its minority/women status and its capability
with other municipal or state agencies for the sole purpose of accessing the firm to their procurement opportunities, unless
otherwise specified by the firm in writing.
I (We) certify under the penalties of perjury that the information contained in any and all application documents submitted to the City
of Miami is correct as per Ordinance No. 10062 as amended.
Firm Name: /AWN 4A / 17 )40,0m POW [`E /rt e.
(If signing as a corporate officer, kindly affix corporate seal)
fir ofra ii S'0A GWwx /
(Name, Title& Date)
dakrytva2 01/6/644
(Name, Title & Date)
r
This application must be signed by at least one general partner of a partnership or the proprietor of a sole proprietorship or all partners
ofa' int t r
NOTARIZA'
COUNTY, SS
COUNTY OF D E Date:
That eice4-7 i sQ/ SQL
foregoing instrument asou syct and !�
That he/she has produced if- Li �r(3LO /32
NOTARY PUBLIC;
My Commission Expires:
City of Miami
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42_ op
y appeared before me and acknowledged the
as identification.
\ MY COk#3.:1SSION # CC9$�i743
EMPIRES: 111,ici.tbrlC. 2 '.;4 J.
Bcnd011 4ataIp Public t]ndarwraer
Bid No. 03-04-012