HomeMy WebLinkAboutMinority Affidavit 44.4. MINORITY/WOMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT
Please Check One Box Only [ ] Hispanic [ ] Female [ ] Black [ ] 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 firm's 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.
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Firm Name: ti 0 I � D1`I'j yl2 v i =�
(If signing as a corpol'te of Lir, kindly affix corporate seal)
d fires. 5)344 go / h � Sec . 71r�ea.d, 5%0/4
ame, Tit�1D/� fame, Title'Date,3
pplication 4i us{ be signe
rietorship or a 1 partners of
ne general partner of a
NOTARIZATION
COUNTY, SS
COUNTY OF DADE4 f f r Date:
That: �Gt �fp' d� personally appeared before me and
acknowledged the foregoing stnimel a hi r act and deed,
That he/she has produced no LA) >t () r ' I �e ( /? t // as identification.
of a sole
IRIS JILL HOLZBERG
NOTARY PUBLIC OF NEW JERSEY
MY COMMISSION EXPIRES
09/07/2006
I.D. NO. 2278978
FAILURE TO COMPLETE. SIGN, AND RETURN THIS FORM MAY DISQUALIFY THIS BID.
City of Miami
BId No. 05-06-034
NOTARY PUBLIC:
My Commission Expires:
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