HomeMy WebLinkAboutMinority Affidavit 74.4. MINORITY/WOMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT
Please Check One Sox Only [ Female [ ] Black [ ) Not Applicable
] Hispanic [ ] p
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 >vlinority and Women Business Enterprise Procedures;
2) that if at any time information submitted
prove to be false, inaccurate, or mislead
Master Bidder list with no further consider
3) that the City of Miami maint ins the
found that false, inaccurate
occurred;
dersigned applicant in his/her Bidder Application should
cant's name will be struck from the City of Miami's
to this applicant;
award of bid/contract, to revoke the award, should it be
ation or a change in the original information have
4) to notify the City of Miami wi hin hrty (3) days of any change in the firm's ownership, control,
management or status as an on ping minori /women business concern as indicated on the Bidder
Application, and that the City of iami, 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.
1 (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:
(If signing as a corporate officer, kindly affix corporate sea!)
(Name, Title & Date) (Name, Title & Date)
This application must be signed by at least one general partner of a partnership or the proprietor of a sole
proprietorship or all partners of a joint venture.
NOTARIZATION
COUNTY, SS
COUNTY OF DADE Date:
That:
acknowledged the foregoing instrument as his/her act and deed.
That he/she has produced as identification.
NOTARY PUBLIC:
My Commission Expires:
FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY THIS BID.
personally appeared before me and
City of Miami Page 31
Bid No. OS-06-006