HomeMy WebLinkAboutMinority Affidavit 34.4. NIINORITY/WOMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT
Please Check One Box Only [] Hispanic anic [ 'Female ack [ ] Not Applicable
If business is not 51% minority/female owned , affidavit does not apply. if no 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 firm's ownership, control,
management or status as an ongoing minority/women business concern as e der a firmn the registrationBidder
Application, and that the City of Miami, upon a finding to the contrary, may
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: ) C �� cite?Jn ev/Atoll DLO �- CJ
(If signing as a co • orate officer, kindly affix corporate sea
(Name, TitJa.& Date)ansicz
(Name, Title & Date)
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This application must be signed by at least one genera artner of a partnership or the proprietor of a sole
proprietorship or all partners of a joint venture.
COUNTY, SS
COUNTY OF DADE k0/��°0
That:
acknowledged th oregoing instrument as his/her act and deed.
,`' Nis ' PrQu ell d D. Elliott.
` .- P�`�, Commission #i)D24�663
. ,:�_ Expires: Oct T1�1u, 2007
Bonded
y��lOF`1`
Atlantic Bonding Co., Inc.
NOTARIZATION ,�y_�
Date: %70,4 2',
personally appeared before me and
as identification.
NOTARY PUBLIC:
My Commission Expires: /0 a7
FAILURE TO COMPUTE. SIGN. AND RETURN THIS FORM MAY DISQUALIFY THIS BID,
City of Miami
Bid No. 05-06-006
Page 31