HomeMy WebLinkAboutattachmentKPREVIOUS CONTRACT NO. H-5-01-090-81
ATTACHMENT"K"
MINORITY CERTIFICATION STATUS
BID NO. H-9-03.242-B1
Dear Business Owner:
If you are a minority and/or woman owned business please complete and return this form. This information will assist us in
identifying your Minority and/or Woman Owned Business in our data base for future procurement and contracting opportunities
with Broward County Board of County Commissioners.
This form is not intendafirm. It omplet yloureused internlly for certification. They canobeaelon purposes and sent to ached at 954-357 78DD, the Office of Equal
Opportunity who you must contact to
ETHNIC GROUP STATUS: Specify the ethnic group and percentage of ownership of the person(s) who owns and controls
(management & operational) 51% or more of the firm.
AFRICAN-AMERICAN MALE %
FEMALE %
HISPANIC-AMERICAN MALE %
FEMALE %
CAUCASIAN FEMALE_ %
ASIAN-AMERICAN MALE %
FEMALE %
NATIVE-AMERICAN MALE %
FEMALE %
DEFINITIONS:
African -American - any black individual of the racial groups of Africa: Asian American - persons whose origins are from
Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U.S. Trust territories of the Pacific, Northern Marianas, Laos, .
Cambodia, Taiwan, India, Pakistan and Bangladesh, Hispanic -American - persons of Spanish or Portuguese culture including
origins in Mexico, South America, Central America,
awomen Islands:
that a sNative
ool included n therabove categories. sons having origins in
any of the original peoples of North America, Caucasian Female
Are you currently certified as a minority vendor? With what agency(s)
Comments:
Firm Name
FE1 #
Date
Signature
R.MIRS-PB09-2003