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Has your firm (under any name) or any of its owners, Board of Directors, officers or management personnel, ever withdrawn an application for any of the programs listed above, or ever been denied certification, decertified, or debarred or suspended or otherwise had bidding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:
Lorem ipsum dolor sit amet.

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: Lorem ipsum dolor sit amet
(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: Lorem ipsum dolor sit amet.
(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:
Lorem ipsum dolor sit amet

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:
Lorem ipsum dolor sit amet.

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:
(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:

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. $
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. $
3. $
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