Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
GMSDC Certification Pre-eligibility Requirements:
Dear Applicant:
Thank you for your interest in certification with the Georgia Minority Supplier Development Council (GMSDC).
Before you begin the process, we want to make sure that your company is eligible for certification. Please
answer the five questions below. To precede with certification you answer must be YES to each of the
questions. If that is not the case then, you WOULD NOT be eligible for certification with GMSDC.
1.
Is your business owned, operated
AND controlled by 51% ethnic
minority owners(s)?
Yes
No
2.
3.
4.
Are the ethnic minority owner(s)
who make up 51% or greater
ownership of the business U.S.
Citizens?
Yes
Do the ethnic minority owner(s)
who hold majority ownership in
the business, hold the highest
executive titled position within the
company: (i.e., CEO, President,
Chairman, etc)?
Yes
Is the company headquartered in
Georgia?
Yes
Ethnic Minorities are defined as:
 Asian Pacific
Origin in Japan, China, the Philippines, Vietnam, Korea,
Samoa, Guam the US Trust Territory and Pacific Island,
the Northern Marinas Islands, Laos Kampuchea
(Cambodia), Taiwan, Burma, Thailand, Malaysia,
Indonesia, Singapore, Brunei, Republic of the Marshall
Islands, or the Federated States of Micronesia.
 African American
 Hispanic
Citizens with origin in Spain or Portugal are NOT eligible
 Native American
American Indianan, Eskimos, Aleuts and Native
Hawaiians
 Asian Indian
Origins in India, Pakistan and Bangladesh
No
No
No
5.
Is your company a “for profit”
business?
Yes
No
Non-Profit organizations do not qualify for certification.
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
Congratulations:
If you are proceeding to this page, then you have answered YES, to each of the five questions in the Pre-eligibility
Requirements section. First we will describe the certification process.
Certification Cost - $500 – Non-refundable
Renewal Cost -$350 – Non-refundable
Certification is good for one year
The graphic below depicts the steps in the certification process. The timeline for these events can range from
thirty (30) to forty-five (45) depending on your submission of documentation.
Please answer all application questions as completely as possible. When answers require more space, use
additional paper properly identifying the item referred by the appropriate number. If a particular question does
not apply to your business operation, write not applicable (NA) in the space provided. Please read carefully the
list of required documentation in the Certification Checklist.
If you questions regarding the status of you application, please email mailto:certify@gmsdc.org.
Please return this registration package to:
Georgia Minority Supplier Development Council (GMSDC)
Certification Department
759 W Peachtree Street NE
Suite 107
Atlanta, Georgia 30308
For information, telephone: 404-589-5929
E-mail: certify@gmsdc.org
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
2012 GMSDC Certification Application
ALL APPLICABLE QUESTIONS MUST BE ANSWERED COMPLETELY
1. Federal EIN:
2. Company Name:
3. Address:
State: GA
4. Phone:
5. Mailing Address (if different):
State:
6. Web Site:
City:
Zip:
FAX:
City:
Zip:
7. Primary Email (owner):
8. Secondary Email:
9. Business Description:
Give a to-the point description of
company product(s), services(s) or
type of construction. If you offer more
than one product/service, list primary
product first. This description will
appear in database.
10. NACIS Codes:
1.
2.
11. Date Business Established:
12. Annual Gross Receipts:
3.
5.
(m/d/yyyy)
$
13. Total Number of Employees
14. Type of Business:
4.
Minority Employees:
Broker/Agent (BA)
Manufacture (MF)
Construction Contractor (CC)
Manufacture Rep (MR)
Consultant/ Professional
Service Contractor (SC)
Distributor (D)
Other
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
15. Legal Business Structure:
Corporation
Limited Liability Corporation/Company (LLC)
Sole Proprietary
Limited Liability Partnership (LLP)
General Partnership
Other
16: Please list each owner, proprietor, partner, office, member, director and shareholder. The names listed should
include Minority Members and Non-Minority Group Members. Be sure to list each ethnic origin. Under ownership
column note is S- (stockholder, proprietor or partner) of D (director/and or officer) Citizenship Status – 1=By birth or 2naturalized citizen.
Name/Title
Ethnic Origin
Ownership Role:
1.
1.
3.
1.
5.
Ownership Percentages
1.
Voting
Percentages
Citizenship
1
2
1
2
1
2
1
2
1
2
1.
3.
1.
5.
4
Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
Contribution of Each Owner
Actual Money Value of Equipment
Provide separate list and
description
Expertise in
this Business
Value of Real Estate
Provide separate list and
description
Years
1.
Years
2.
Years
3.
Years
4.
Years
5.
17. Geographic Market:
18. Provide three current
customers:
Local
Regional
National
International
Company:
Address:
City:
State:
Zip:
Buyer:
Phone:
Product/Service Provided:
Dollar Value:
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
Customer 2:
Company:
Address:
City:
State:
Zip:
Buyer:
Phone:
Product/Service Provided:
Dollar Value:
Customer 3:
Company:
Address:
City:
State:
Zip:
Buyer:
Phone:
Product/Service Provided:
Dollar Value:
19. Owner Contact Info:
Name:
Title:
Telephone:
E mail:
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
20. Secondary Contact Info:
Name:
Title:
Telephone:
E mail:
21. Other Certifications:
22. Is your parent company or
subsidiary Certified by
another NMSDC affiliate
council
23. Has your firm ever applied
for certification before?
Yes
No
If yes, whom:
Yes
No
If yes, whom:
24. Type of Acquisition:
Bought Existing Business
Stated Business
Secured a Franchise
Merger or Consolidation
Other (Please specify)
25. Gross Receipts for last three years. If not in A. Year
business three years, gross receipts to date.
B. Year
C. Year
26. Are business premises:
Owned
Gross Receipts
Gross Receipts
Gross Receipts
Leased
Home Based
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
26a. List or attach location of additional
facilities:
27, If license or permit is required to provide product or service, give information as follows. If more room is
required, identify by number and attach:
Name of License Holder
Type of License/Permit
License Number
1.
2.
3.
4,
28. Identify those individuals (owners, non-owners and key employees)who are responsible for the day to day
operations and policy decision making including those with prime responsibility for:
Operations
Name
Title
Ethnic Origin
Financial Decisions
Signatory on major documents
Personnel Management
Marketing/Sales
Payroll
Estimating
Purchasing of Major Items
Supervision of Field Operations
What jobs firm will take
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
29. Does your company share any resources with any other
firm or individual? (office facilities, storage space,
equipment, personal inventory, financing etc.
Yes
No
If yes, identify and explain fully:
30: Identify any owner. Management official or employees
of your company who is associated with any other business.
Explain fully and identify the business or person with whom
you have an agreement and attach any written agreement
(and explain any oral intended agreement?
31.Does the applicant business have any subsidiaries or
affiliates or is it a subsidiary of another concern
Yes
No
32 If the applicant business and or owner concern involved
in any present or pending lawsuit? If yes, provide details on
a separate sheet.
31A. If yes, provide the name, address, telephone
number of the subsidiary, affiliate or parent company.
Also describe the relationship of the applicant company
to the subsidiary, affiliate or parent company.
Yes
No
33. Provide Current Bank References:
A. Name of Bank:
Address:
City/State/Zip:
Type of Account:
Credit Line:
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
B. Name of Bank:
Address:
City/State/Zip:
Type of Account:
Credit Line:
34. If company is a Distributor, please complete :
Average Dollar Value of Inventory:$
35. If company is a Manufacture, list basic equipment and indicate whether equipment is leased or owned:
Basic Equipment
Leased/Owned
Leased
Owned
Leased
Owned
Leased
Owned
Leased
Owned
Leased
Owned
Leased
Owned
Leased
Owned
Leased
36: If company is a Contractor, please complete the following:
Owned
License Number:
License Certificate:
Trade Specialty:
Union Name/Local:
Union Affiliation:
Most Recent Project:
Project Name:
Start Date:
Geographical Area:
Dollar Value:
Finish Date:
Responsible Managing Officer:
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
37: Transportation Company Information:
Common Carrier Operating Authorities:
Operating Status:
Interstate Intrastate
List commodities You Transport:
Independent Carrier
Insurance Carrier
37A. Transportation Equipment: Please forward copies of all applicable vehicle title and or lease agreements with this
application.
Vehicle Equipment
Owned/Leased & Quantity
Registration Number
Bonding: Is the firm or Sole Proprietorship Bonded?
Bonding Amount:
Yes
No
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
DECLARATION OF CERTIFICATION OF MINORITY STATUS
I (We) have completed and submitted the Minority Supplier Registration and Database Input Form as requested by
the GEORGIA MINORITY SUPPLIER DEVELOPMENT COUNCIL and hereby certify that the information contained herein
and all attachments submitted are true and correct and accurate to the best of my (our) knowledge and belief. I (We)
understand that this Declaration of Certification and the criteria set forth have been developed according to the
guidelines established by the NATIONAL MINORITY SUPPLIER DEVELOPMENT COUNCIL. The certification, when granted,
will be for a one (1) year period. I (We) further understand that completion and submission of this form, together with all
attachments hereto, is not necessarily the sole criteria for determining certification of minority status by GEORGIA
MINORITY SUPPLIER DEVELOPMENT COUNCIL.
I (We) acknowledge that if the Council discovers that a statement has been made herein which the applicant knows
to be false, the certification process will be terminated immediately. I (We) agree that all materials submitted with this
package shall become the property of the Council.
I (We) further agree that once certified, the continued certification and registration by the GEORGIA MINORITY
SUPPLIER DEVELOPMENT COUNCIL will be according to the guidelines, rules and regulations of the GEORGIA MINORITY
SUPPLIER DEVELOPMENT COUNCIL and the NATIONAL MINORITY SUPPLIER DEVELOPMENT COUNCIL and may be
amended for time to time. Termination of my (our) status may be based upon, but not necessarily limited to, any one of
the following:
1. Cessation of business operation by the minority business concern.
2. Discovery that any false information was knowingly supplied to the GEORGIA MINORITY SUPPLIER DEVELOPMENT
COUNCIL in the completion of this form or as contained in any attachments submitted.
3. Failure to provide timely notice or withholding of any notice to the GEORGIA MINORITY SUPPLIER DEVELOPMENT
COUNCIL of the transfer or loss of ownership and/or management and control of the business concern by its
minority group members.
4. Failure or refusal to allow the GEORGIA MINORITY SUPPLIER DEVELOPMENT COUNCIL and/or its representative
access to the company’s place of business upon reasonable notice and demand for the purpose of a site visit.
5. Sale, exchange, or transfer of ownership of the minority business concern, if such transfer results in the loss of
control and ownership of the business concern by the minority group members.
I (We) understand and agree that GEORGIA MINORITY SUPPLIER DEVELOPMENT COUNCIL reserves the right to
request any further and additional information that it may deem necessary to substantiate the information and
representations made by the applicant (applicants) for certification. I (We) declare that the company in whose name this
application is being submitted is at least fifty-one percent (51%) owned by one or more minority individuals (as defined
herein) and such individuals control, operate and manage the company.
The undersigned hereby agrees (agree) to hold GEORGIA MINORITY SUPPLIER DEVELOPMENT COUNCIL free and
harmless from any and all claims, demands, and damages whatsoever arising out of the presentation of this application
and agrees to indemnify and hold GEORGIA MINORITY SUPPLIER DEVELOPMENT COUNCIL harmless for any and all
liability in connection with the certification of the information contained in this application.
The undersigned hereby declares (declare) under penalty of perjury that all statements made in this
application and any attachments hereto and true and correct. I understand that the $500.00 Registration
Fee is included and non-refundable
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
Business Name
Signature of all Proprietor, Partners and President of the Corporation
Date
Date
Date
Date
Date
Please have this form NOTARIZED, retain a copy of this form for your files and return the original and the attachments to:
Georgia Minority Supplier Development Council
Attention: Certification Department
759 W Peachtree Street NE
Suite 107
Atlanta, Georgia 30308
404-589-4929
certify@gmsdc.org www.gmsdc.org
State of
County of
On
, before me
the undersigned Notary Public, personally appeared (name)
personally known to me, or proved to me on the basis of satisfactory evidence, to be the person(s) whose name (s)
is/are subscribed to the within instrument, and acknowledged to me that he/she they executed in the same in his/her
their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s) of the entity upon
which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Notary Public_______________________________________________
(Seal)
Commission Expires:
NOTE: Public Law 99-272, the “Consolidated Omnibus Budget Reconciliation Act of 1985,” which amends Section 16 of the Small
Business Act, establishes penalties of up to a $50,000 fine or imprisonment of up to five years, or both, for misrepresenting, in
writing, the status of any concern or small business owned and controlled by socially and economically disadvantaged individuals (a
“DBE”) in order to obtain for oneself or another any prime subcontract to be awarded as a result or in furtherance or any provision of
federal law that specifically references Section 8(D) if the Small Business Act for a definition of eligibility.
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
Payment Authorization Form
Directions: Please complete this form in its entirety and include it with the certification application.
Transaction Type:
Billing Name:
Invoice
Company Name:
Sales Receipt
Email:
Other
Zip Code:
Payment Type:
Credit Card Type:
Check
Credit Card Number
-
Expiration Date-M/YYYY:
Security Code:
Amount:
Event/Program:
Contact Name:
Contact Phone:
Authorization:
Signature:
Date:
GMSDC Staff:
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
DOCUMENTATION ATTACHMENTS – Please include appropriate documentation with the application and please
indicate which documents are attached. Please submit in sections as indicated. Do Not submit in ring binders. The
documentation required for certification is listed below, but is not limited to:
ALL BUSINESSES ARE REQUIRED TO SUBMIT:
Section 1
Fictitious Business Statement (if applicable)
Proof of U.S. Citizenship (birth certificate and Drivers License)
Proof of Ethnicity for Owner(s), Partners, Shareholders (birth certificate)
Resume(s) of owner(s), partners or shareholders
Indian/Native Americans Blood Degree Certificate (i.e. tribal registry letter, tribal roll register number) [if applicable]
Section 2
LLCs
Articles of Organization
Operational Agreement
Organizational Agreement
Minutes of 1st Board Meeting
Copies of Stock Certificates (units)
Current Stock Ledger (units)
Proof of Stock Purchase (units)
Partnerships:
Partnership Agreements
Buy Out Rights
Profit Sharing
Current Partnership
Third-party agreements: management service agreements
Proof of Capital Investment
CORPORATIONS SUBMIT:
Article of Incorporation
Certificate of Corporation
Minutes of 1st Board Meeting
Copies of Stock Certificates
Current Stock Ledger
Corporate Bylaws
Proof of Stock Purchase
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Georgia Minority Supplier Development Council
759 W Peachtree Street NE Suite 107404-589-4929Atlanta, GA 30308
Section 3
Two Years of Federal Tax Returns (Business)*
Financial Statements (P & L, statement of cash flows, balance sheet)
Notes Payable (if any)
Bank Signature Card (copy signature care or letter from bank)
Cancelled Business Check (Not a voided check)
*Personal taxes if in business less than 1 year
** Proforma financial statements to GAAP (Generally Accepted Accounting Principles) standards.
Section 4
Applicable Operating Business License and/or permits
Lease Agreements /Warranty Deed/Security Deed
Equipment Rental and Purchase Agreements (if applicable)
Contract or work history for the past three years (if applicable) (name/contact type of work or contract
received)
Equipment owned or available (include description of equipment, year acquired, and current value)
Proof of Bonding Capacity (if applicable)
$500 non-refundable processing fee
.
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