Section 1: CERTIFICATION INFORMATION
A: Prior/Other Certifications
Is your firm currently certified for any of
the following programs?
(If yes, check appropriate box(es))
DBE:
8(a):
SDB:
Name of certifying agency:
Agency name
Has your firm"s state UCP conducted an on-site visit?
Yes, on 03/09/2010 State:
Kentucky
B: Prior/Other Applications and Privileges
Has your firm (under any name) or any of its
owners, Board of Directors, officers or management personnel, ever
withdrawn an application for any of the programs listed above, or ever
been denied certification, decertified, or debarred or suspended or
otherwise had bidding privileges denied or restricted by any state or
local agency, or federal entity?
Yes, on 03/01/2010
If yes, identify State and name of State, Local, or Federal agency and
explain the nature of the action:
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Section 2: GENERAL INFORMATION
A: Contact Information
(1) Contact person and Title: Beeler (2) Legal name of firm: Fake Company
(3) Phone #: 502-876-2397 (4) Other Phone #:
502-819-0559 (5) Fax #: 502-583-2344
(6) Email: justin.beeler@gmail.com (7)
Website (if have one): http://justinbeeler.com
(8) Street address of firm (No P.O. Box): 214
S. 8th St City: Louisville County/Parish: Jefferson State: Alabama
Zip: justin
(9) Mailing address of firm (if different): 214
S. 8th St City: Louisville County/Parish: Jefferson State: Alabama
Zip: justin
B: Business Profile
(1) Describe the primary activities of your
firm:
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(2) Federal Tax ID
(if any):
12345678
(3) This firm was established on:
06/01/2009
(4) I/We have owned this firm since:
02/01/2009
(5) Method of acquisition
(check all that apply):
Started new business
Bought existing business
Inherited business
Secured Concession
Merger or consolidation
Other
(explain) Other (6) Is your firm "for profit"?
Yes
(7) Type of firm
(check all that apply):
Sole Proprietorship
Partnership
Corporation
Limited Liability Partnership
Limited Liability Corporation
Joint Venture
Other, Describe:
other
(8) Has your firm ever existed under different ownership, a different
type of ownership, or a different name?
No
If Yes, explain:
(9) Number of employees: Full-time:
5
Part-time:
3 Total:
8
(10) Specify the gross receipts of the firm for the last 3 years:
Year |
Total receipts |
2009 |
$10000 |
2008 |
$20000 |
2007 |
$30000 |
C: Relationships with Other Businesses
(1) Is your firm co-located at any of its
business locations, or does it share a telephone number, P.O. Box,
office space, yard, warehouse, facilities, equipment, or office staff,
with any other business, organization or entity?
Yes
If Yes, identify: Other Firm"s name:
Mo"
Better Marketing
Explain nature of shared facilities:
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(2) At present, or at any time in the past, has your firm:
(a) been a subsidiary of any other firm?
No
(b) consisted of a partnership in which one or more of the partners are
other firms?
No
(c) owned any percentage of any other firm?
No
(d) had any subsidiaries?
Yes
(3) Has any other firm had an ownership interest in your firm at present
or at any time in the past?
No
(4) If you answered "Yes" to any of the questions in (2)(a)-(d) and/or
(3), identify the following for each:
|
Name |
Address |
Type of Business |
1. |
another fake company |
214 S. 8th St. |
Marketing/Consulting |
2. |
|
|
|
3. |
|
|
|
D. Immediate Family Member Businesses
Do any of your immediate family members own
or manage another company?
Yes
If Yes, then list:
|
Name |
Relationship |
Company |
Type of Business |
Own or Manage? |
1. |
Jeremy Beeler |
Brother |
Jeremy"s Plumbing |
Plumbing |
Own |
2. |
|
|
|
|
Own |
Section 3: OWNERSHIP
Identify all individuals or holding companies with any ownership
interest in your firm, providing the information requested below:
A. Background Information
(1) Name: Alicia Beeler |
(2) Title: VP |
(3) Home Phone #: 502-819-0559 |
(4) Home Address (street and number): 5523 Shorewood Ave. |
City: Louisville |
State: Kentucky |
Zip: 40214 |
(5) Gender: Female |
(6) Ethnic group membership (check all that apply):
Black Hispanic
Native American Asian Pacific
Subcontinent Asian Other (specify)
|
B. Ownership Interest
(1) Number of years as owner: 5
(3) Percentage owned: 50%
(4) Familial relationship to other owners: Wife
|
(2) Initial investment to acquire ownership interest in firm:
Cash: $10000
Real Estate: $40000
Equipment: $2000
Other: $3400
|
(5) Shares of Stock:
Number |
Percentage |
Class |
Date acquired |
Method acquired |
234 |
3 |
A |
|
Cash |
(6) Does this owner perform a management or supervisory function for any
other business?
No
If Yes, identify: Name of Business:
Function/Title:
(7) Does this owner own or work for any other firm(s) that has a
relationship with this firm
(e.g. ownership interest, shared
office space, financial investments, equipment, leases, personnel
sharing, etc.)?
No
If Yes, identify: Name of Business:
Function/Title:
Nature of Business Relationship:
C. Disadvantaged Status - NOTE: Complete this section only for
each owner applying for DBE qualification (i.e., for each owner
claiming to be socially and economically disadvantaged)
(1) What is the Personal Net Worth (PNW) of
the owner(s) applying for DBE qualification?
$10
(2) Has any trust been created for the benefit of this disadvantaged
owner(s)?
No
If Yes, explain:
Section 3: OWNERSHIP
Identify all individuals or holding companies with any ownership
interest in your firm, providing the information requested below:
A. Background Information
(1) Name: Justin Beeler |
(2) Title: President |
(3) Home Phone #: 502-876-2397 |
(4) Home Address (street and number): 5523 Shorewood Ave. |
City: Louisville |
State: Kentucky |
Zip: 40214 |
(5) Gender: Male |
(6) Ethnic group membership (check all that apply):
Black Hispanic
Native American Asian Pacific
Subcontinent Asian Other (specify) Caucasian
|
B. Ownership Interest
(1) Number of years as owner: 10
(3) Percentage owned: 50%
(4) Familial relationship to other owners: Husband
|
(2) Initial investment to acquire ownership interest in firm:
Cash: $1200
Real Estate: $12000
Equipment: $1200
Other: $13000
|
(5) Shares of Stock:
Number |
Percentage |
Class |
Date acquired |
Method acquired |
234 |
40 |
a |
07/20/2010 |
cash |
(6) Does this owner perform a management or supervisory function for any
other business?
No
If Yes, identify: Name of Business:
Function/Title:
(7) Does this owner own or work for any other firm(s) that has a
relationship with this firm
(e.g. ownership interest, shared
office space, financial investments, equipment, leases, personnel
sharing, etc.)?
Yes
If Yes, identify: Name of Business:
Acme
Consulting Co. Function/Title:
Consultant
Nature of Business Relationship:
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C. Disadvantaged Status - NOTE: Complete this section only for
each owner applying for DBE qualification (i.e., for each owner
claiming to be socially and economically disadvantaged)
(1) What is the Personal Net Worth (PNW) of
the owner(s) applying for DBE qualification?
$1200000
(2) Has any trust been created for the benefit of this disadvantaged
owner(s)?
Yes
If Yes, explain:
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Section 4: CONTROL
A. Identify your firm"s Officers & Board of Directors
(1) Officers of the Company
Name: |
Title: |
Date Appointed |
Ethnicity |
Gender |
(2) Board of Directors
Name: |
Title: |
Date Appointed |
Ethnicity |
Gender |
(3) Do any of the person(s) listed in (1)
and/or (2) above perform a management or supervisory function for any
other business?
No
If Yes, identify for each:
Person: |
Title: |
Business: |
Function: |
Person: |
Title: |
Business: |
Function: |
(4) Do any of the persons listed in (1) own or work for any other
firm(s) that has a relationship with this firm?
(e.g., ownership
interest, shared office space, financial investments, equipment, leases,
personnel sharing, etc.)
If Yes, identify for each:
Firm Name: |
Person: |
Nature of Business Relationship: |
Firm Name: |
Person: |
Nature of Business Relationship: |
B. Identify you firm"s management personnel who control your
firm in the following areas:
|
Name |
Title |
Ethnicity |
Gender |
(1) Financial Decisions (responsibility
for acquisition of lines of credit, surety bonding, supplies, etc. |
a.
b. |
|
|
|
(2) Estimating and bidding |
a.
b. |
|
|
|
(3) Negotiating and Contract Execution |
a.
b. |
|
|
|
(4) Hiring/firing of management personnel |
a.
b. |
|
|
|
(5) Field/Production Operations Supervisor |
a.
b. |
|
|
|
(6) Office management |
a.
b. |
|
|
|
(7) Marketing/Sales |
a.
b. |
|
|
|
(8) Purchasing of major equipment |
a.
b. |
|
|
|
(9) Authorized to Sign Company Checks (for
any purpose) |
a.
b. |
|
|
|
(10) Authorized to make Financial Transactions |
a.
b. |
|
|
|
(11) Do any of the persons listed in (1)
through (10) above perform a management or supervisory function for any
other business?
No
If Yes, identify for each:
Person: |
Title: |
Business: |
Function: |
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(12) Do any of the persons listed in (1) through (10) above own or work
for any other firm(s) that has a relationship with this firm?
(e.g.
ownership interest, shared office space, financial investments,
equipment, leases, personnel sharing, etc.) No
If Yes, identify for each:
Firm Name: |
Person: |
Nature of business relationship: |
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C. Indicate your firm"s inventory in the following categories:
(1) Equipment
|
Type of Equipment |
Make/Model |
Current Value |
Owned or Leased? |
(a) |
|
|
$ |
|
(b) |
|
|
$ |
|
(c) |
|
|
$ |
|
(2) Vehicles
|
Type of Vehicle |
Make/Model |
Current Value |
Owned or Leased? |
(a) |
|
|
$ |
|
(b) |
|
|
$ |
|
(c) |
|
|
$ |
|
(3) Office Space
|
Street Address |
Owned or Leased? |
Current Value of Property or Lease |
(a) |
|
|
$ |
(b) |
|
|
$ |
(4) Storage Space
|
Street Address |
Owned or Leased? |
Current Value of Property or Lease |
(a) |
|
|
$ |
(b) |
|
|
$ |
D. Does your firm rely on any other firm for management
functions or employee payroll?
No
If Yes, explain:
E. Financial Information
(1) Banking Information
(a) Name of Bank: (b) Phone No.
(c) Address of Bank: City: State: Zip:
(2) Bonding Information:
If you have bonding capacity, identify: (a) Binder No:
(b) Name of agent/broker: (c) Phone No.:
(d) Address of agent/broker: City: State: Zip:
(e) Bonding limit: Aggregate limit: $
Project limit: $
F. Identify all sources, amounts, and purposes of money loaned
to your firm, including the names of any persons or firms securing the
loan, if other than the listed owner:
|
Name of Source |
Address of Source |
Name of Person Securing the Loan |
Original Amount |
Current Balance |
Purpose of Loan |
1. |
|
|
|
$ |
$ |
|
2. |
|
|
|
$ |
$ |
|
3. |
|
|
|
$ |
$ |
|
G. List all contributions or transfers of assets to/from your
firm and to/from any of its owners over the past two years:
|
Contribution/Asset |
Dollar Value |
From Whom Transferred |
To Whom Transferred |
Relationship |
Date of Transfer |
1. |
|
$ |
|
|
|
|
2. |
|
$ |
|
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|
|
3. |
|
$ |
|
|
|
|
H. List current licenses/permits held by any owner and/or
employee of your firm (e.g., contractor, engineer, architect,
etc.):
|
Name of License/Permit Holder |
Type of License/Permit |
Expiration Date |
License Number and State |
1. |
|
|
|
- |
2. |
|
|
|
- |
3. |
|
|
|
- |
I. List the three largest contracts completed by your firm in
the past three years, if any:
|
Name of Owner/Contractor |
Name/Location of Project |
Type of Work Performed |
Dollar Value of Contract |
1. |
|
|
|
$ |
2. |
|
|
|
$ |
3. |
|
|
|
$ |
J. List the three largest active jobs on which your firm is
currently working:
|
Name of Prime Contractor and Project Number |
Location of Project |
Type of Work |
Project Start Date |
Anticipated Completion Date |
Dollar Value of Project |
1. |
|
|
|
|
|
$ |
2. |
|
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|
|
|
$ |
3. |
|
|
|
|
|
$ |
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