HomeMy WebLinkAboutMinority Affidavit 54.4. MINORITY/WOMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT
Pease Check One Sox Only [ ] Hispanic _o Female [ ] Black [ ] Not Applicable
I f business is not 51% minority/female owned , affidavit does apply. If not applicable, notarization is not required.
1 (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
prnve.to he 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.
Firm Name: 6 G+1g4—• e_S 0/U-r
(If signing as a corporate officer, kindly affix corporate seal)
£t/(a/c 4
(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 ake,4No1141 Date: G —43- O e
ThapNtt + ig ,n,p 4C'i o o Ley personally appeared before me and
`as ' cfa /edged tl q,rdr�going instrument as his/her act and deed.
` lTi e/she has'ptbducesl DI_ C 8 .2 / 77 G f' ..2
NOTARY PUBLIC:
as identification,
C /t . 4.e itteA
y•�3- oI
%�r•,• {� ; , , _.. �..,' My Commission Expires:
Ge.rserr 05ed aia57
i'AILURF''O COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY THIS BID.
City of Miami Page 29
Bid No. 05-06.034