HomeMy WebLinkAboutm-wbe affairs reg. affidavit00504. SUPPLEMENT TO DID Ft IIM:.
MINORITY/WOMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT (Page 1 o
Please Check One Box Only:,
Hispanic [. ] Female [ ] Black [ ] Not Applicable
If business is not 51 % minority/female owned, • affidavit does not apply;
notarization is not required,
I (We), the undersigned agree to the following conditions:
1) that we meet the fifty-one percent (61%) ownership and management requirem'
for minority/women registration status . and: will abide by all of the policies ' a
regulations governing the City of Miami Minority and Women Business Enterpr
Procedures;
2) that If at any time information submitted by the undersigned applicant in his
-Bidder Application should drove to be false, inaccurate, or, misleadingapplies
name will be struck from -{the City of Miami's Master Bidder list with no furt
consideration given to thisapplicant;.
3) that the City of Miami -maintains the right,- through award of bid/contract, to rev
the award, should It be found -that false, inaccurate or misleading informationo
change in the original infortnation have occurred;
4) to notify the City of War* within thirty (30) days ofany change in the ::fir
ownership, control,- maneBement or status as an ongoing minority/wo
_ __ _ sines concern::awe_% c hated on _the Bidder Application;_ and that_ the pity
Miami, upon a finding to the contrary, may render a firm's_registration with the_ -
null. and void and ceasetb include that firm In its registered: list of minority -
women -owned busirlesse
5) that the City of Miami has a• right to diligently verify all information submitted
applicant in his/her Bidder Application .to monitor the status of the MinorityNVo
Business ,Enterprise, or[ce?eglstered;
6) that the City of Miami may share a firm's registration -information concerning
minority/women -status-anti its capability with other municipal or state agencies
the sole purpose of accessing the -firm to their procurement opportunities, unl
otherwise specified by the firm in -writing;
I (We) certify under the pen-altiestof perjury that the information contained in any and
application documents su_ bmitted to the City of iMllami is correct as per Ordinance
10062 as amended.
Firm Name:
City of Mimi
Ke—kr,) .
Bid No. 04-05-011
00504, Sal PPJP MENT TO lD FOlart.
MINORITYMIQMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT (Page 2 of
(if -signing as a corporate officer, kindly affix corporate seal)
(Name, Title & Da)
(Name, Title & Date)
This application must be signed ►y-at least:one general -partner-.of a partnership Or- h!1-=.
Proprietor of a sole proprietor.shior all.partners of a joint venturer
•
NOTARIZATION
STATE OF Fort &&
) SS:
COUNTY OF q)GJ
Date: l K 1 ° y
That: ,D li-•crt,.s 4.6 .r•) person II
appeared before me and acknowledged the foregoing instrument as his/her act cI
deed,
,That he/she__ _has._ produced _:
identification:
Rodailio iarvarePpm
!NOTARY- PUBLIC: Pitt canr aii wool
_My Commission Expires:
City of Mlaml = 41
Bid No. 04-05.011