EPA DBE Certification Application 

Environmental Protection Agency 

For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE) 

Under EPA’s Disadvantaged Business Enterprise (DBE) Program 

For Corporations

Business Profile: 

Name of applicant firm: _____________________________________________________________________ 

Name of President/Chief Executive Officer: _____________________________________________________

EIN:_______________________________________ E-mail Address:________________________________ 

Business Address:________________________________ County:__________________________________ 

City:_______________________________ State: _________ Zip Code:_______________________________ 

Phone Number:____________________________ Fax Number: _________________________ 

Mailing Address (if different than above):_________________________ County:_______________________ 

City:_________________________________ State:_______________ Zip Code:_______________________ 

What is the firm’s 4-digit primary North American Industrial Classification (NAIC) code? ______________ 

Are you claiming disabled status? ___ Yes ___ No. (i.e., a United States citizen who has permanent or 

temporary physical or mental impairment that substantially limits one or more of your major life 

activities). If yes, please submit documentation substantiating such disability. 

Is your firm at least 51% owned by a Disabled American? ___ Yes ___ No. 

Is your firm certified by the Small Business Administration under its 8(a) Business Development 

Program? ___ Yes ___ No. If yes, provide PRO-Net number: ______________________________________ 

Is your firm certified by the Small Business Administration under its Small Disadvantaged Business (SDB) 

Program? ___ Yes ___ No. If yes, provide PRO-Net number: _______________________________________ 

Is your firm certified as a DBE by a U.S. Department of Transportation recipient? ___ Yes ___ No. If yes, 

provide State(s) and ID number(s): _____________________________________________________________ 

Is your firm certified by a State government, local government, Indian tribal government, or independent 

private organization? ___ Yes ___ No. If yes, provide ID number the certifying entity: 

_________________________________________________________________________________________ 

Has your firm ever been denied certification by a Federal agency, State government, local government, 

Indian tribal government, or independent private organization? ___ Yes ___ No If yes, provide a copy of 

the prior determination of attempts to obtain certification: _____________________________________ 

_________________________________________________________________________________________ 

_________________________________________________________________________________________ 

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 

OMB Control No: 2090-0030 

Approval Expires: XX/XX/XX
Do you have any other certification as a disadvantaged business entity, i.e, MBE, DBE, WBE, etc? 

 ___Yes ___ No. If yes, provide State(s) and ID number(s) ________________________________________ 

In accordance with 13 CFR §124.103, designated group members are presumed to be socially

disadvantaged. Designated group members are individuals who hold themselves out to be and are

identified by others as Black Americans, Native Americans (American Indians, Eskimos, Aleuts, or

Native Hawaiians), Hispanic Americans, Subcontinent Asian Americans, Asian Pacific Americans,

and any other groups designated by the Small Business Administration (SBA). If an individual is

claiming to be a member of a designated group, complete Section A of this application. If an

individual is not claiming to be a member of a designated group, complete Section B of this

application. All applicants must complete Sections C, D, and E of this application. 

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 2
SECTION A 

Eligibility Statement - Designated Group Members

Social Disadvantage 

1. Is your firm at least 51% owned by a U.S. citizen? ___ Yes ___ No. If your firm is not at least 51% 

owned by a U.S. citizen, stop here. You are not eligible to participate as a DBE under EPA’s DBE

Certification Program. 

2. List all individuals claiming disadvantaged status:

 

 Name of Individual Other last U.S. Citizen Place of Group Sex

Names Used Y/N Birth Membership M/F 

 ___________________ ___________ ________ ___________ _______ _____ 

 

 ___________________ ___________ ________ ___________ _______ _____ 

 

 ___________________ ___________ ________ ___________ _______ _____ 

a) If you are a naturalized citizen, please provide the following as Attachment A-1, (a) naturalization

number; (b) date of citizenship; and (c) county, state and court. 

SECTION B 

Eligibility Statement - Non Designated Group Members 

1. List all individuals claiming disadvantaged status:

 

 Name of Individual U.S. Citizen Race Sex 

Y/N M/F 

 _______________________________ ________ ________ _____ 

 _______________________________ ________ ________ _____ 

 _______________________________ ________ ________ _____ 

 

 _______________________________ ________ ________ _____ 

 

a) If you are a naturalized citizen, please provide the following as Attachment B-1, (a) 

naturalization number; (b) date of citizenship; and (c) county, state and court.

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 3
For this section, any individual claiming social disadvantage must provide a separate response for 

questions 3 and 4. 

Social Disadvantage 

2. I, ____________________________________ have personally suffered social disadvantage based 

on my identification as __________________________________. 

(A claim of social disadvantage must include at least one objective feature that has 

contributed to social disadvantage, such as race, ethnic origin, gender, physical handicap, 

long-term residence in an environment isolated from the mainstream of American society, or

other similar causes not common to individuals who are not socially disadvantaged.) 

3. Document how your ability to compete in the free enterprise system has been impaired by such 

things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or 

leases; restriction of your market to certain racial, ethnic or social groups; underemployment or

unemployment, etc., as compared to others in the same or similar line of business who are not 

socially disadvantaged. Provide as Attachment B-2.

4. Attach a narrative describing how you personally experienced social disadvantage in 

American society. When writing your narrative, be as specific and detailed as possible. Where 

applicable, each statement of alleged discrimination should be supported by documented

evidence such as affidavits, denials of loan applications, denials of employment opportunities 

(including non-selection for particular jobs, denials of promotions, or unequal work environment 

or treatment), and documents to support any formal action taken by you because of alleged

discrimination. You must demonstrate how your identification, as described in the paragraph 

above, has negatively impacted your entry into or advancement in business. You must address 

disadvantage in education, employment, and business history, where applicable. Examples of

discrimination include, but are not limited to: unequal access to colleges or professional schools;

exclusion from professional or business associations; being denied educational honors or

recognition; experiencing discriminatory social pressure which discouraged you from pursuing a

professional or higher education or forced you into non-professional or non-business fields;

discrimination in employment opportunities or pay and fringe benefits; unequal access to 

business credit or capital; and discrimination in the awarding, bidding process, or negotiating of

government or private sector contracts. Provide as Attachment B-3. 

SECTION C 

(All applicant firms must complete) 

Economic Disadvantage 

1. Is the net worth of each individual(s) claiming disadvantaged status less than $750,000, excluding

ownership interest in the applicant corporation and equity in the individual(s) primary 

residence? ____ Yes ____ No. 

2. For individual(s) claiming disadvantaged status, list your personal net worth, excluding the 

ownership interest in the applicant corporation and the equity in the individual(s) primary 

residence. 

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 4
Name Average 2-year Personal Total 

 Income Net Worth Assets

________________________________ ______________ __________ _______ 

________________________________ ______________ __________ _______ 

________________________________ ______________ __________ _______ 

________________________________ ______________ __________ _______ 

3. Have any individual(s) listed in number 2 above transferred any assets within two years, in full 

or in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes,

provide the following information as Attachment C-1: the date of transfer; to whom the assets 

were transferred; amount paid for the assets; and the market value of the assets at the time of

transfer. Individual(s) may exclude assets transferred to an immediate family member that are 

consistent with the customary recognition of special occasions, such as birthdays, graduations,

anniversaries and retirements. Individual(s) may also exclude any transfers to an immediate 

family member if for educational, medical or essential support purposes. 

4. Each individual listed in number 2 above, certifies that because of racial and/or ethnic prejudice, 

and/or cultural bias, his/her ability to compete in the free enterprise system has been impaired

due to diminished capital and credit opportunities as compared to others in the same or similar

line of business that are not socially disadvantaged.

SECTION D 

(All applicant firms must complete) 

Ownership 

1. If more than one class of stock, provide information for each class:

 Voting Non Total

Voting 

a) Total number of shares authorized: _____ ______ _____ 

b) Total number of shares currently outstanding: _____ ______ _____ 

2. List all individuals, entities, and/or trusts, which have an ownership interest in the applicant firm. 

 Name Title Voting Ownership Percentage 

 Non-Voting Total 

 

________________ ______ _____ ____________ __________ 

3. Do disadvantaged individuals receive at least 51% of the annual distributions of dividends paid on

the stock of a corporate applicant firm? ___ Yes ___ No. If no, please explain and provide as

Attachment D-1. 

4. Do disadvantaged individuals own 51% or more of each class of voting stock outstanding and 51% of

the aggregate of all stock outstanding? ___ Yes ___ No. 

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 5
5. Will disadvantaged individuals receive 100% of the unencumbered value of each share of stock 

owned in the event that the stock is sold? ___Yes ___ No. If no, please explain and provide as

Attachment D-2.

6. If the corporation dissolves, will disadvantaged individuals receive at least 51% of the retained

earnings and 100% of the unencumbered value of each share of stock he or she owns? 

___ Yes ___ No. If no, please explain and provide as Attachment D-3. 

7. Is ownership by any individual claiming disadvantaged status subject to conditions precedent,

conditions subsequent, executory agreements, voting trusts, shareholder agreements or other similar

arrangements, which may impact the unconditional ownership of such individuals? ___ Yes ___ No. 

If yes, explain as Attachment D-4. 

8. Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did the change in

ownership affect the disadvantaged status of your firm? Please explain as Attachment D-5. 

For community property residents only. If you are a married disadvantaged owner, and your

spouse is not disadvantaged, please complete the chart below, and provide evidence that you have a

majority interest in the business. 

Name of Disadvantaged Owner State of Residence Percent Transferred

____________________________ _______ __________________ 

____________________________ _______ __________________ 

____________________________ _______ __________________ 

 

____________________________ _______ __________________ 

SECTION E 

(All applicant firms must complete)

Control 

1. Disadvantaged individuals control the board of directors by virtue of the fact that (select only one 

below):

 ____ a) A single disadvantaged individual owns 100% of all the voting stock of the

applicant business.

 ____ b) A single disadvantaged individual owns at least 51% of all voting stock, is on the

Board of Directors, and no super majority voting requirements exist for shareholders to 

approve corporate actions.

 ____ c) A single disadvantaged individual owns at least 51% of all voting stock, is on the

Board of Directors, and owns at least the percentage of voting stock needed to overcome

the super majority voting requirements which exist for shareholders to approve corporate 

actions.

 ____ d) More than one disadvantaged individual owns at least 51% of all voting stock, all 

such individuals serve on the Board of Directors, no super majority voting requirements 

exist for shareholders to approve corporation actions, and the disadvantaged

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 6
shareholders can demonstrate they have made enforceable arrangements to permit one of

them to vote the stock of all as a block without holding a shareholder meeting.

 ____ 

e) More than one disadvantaged individual owns at least 51% of all voting stock, all 

such individuals serve on the Board of Directors, in total all own at least the percentage of voting stock 

needed to overcome the existing super majority voting requirements which exist for shareholders to

approve corporate actions, and the disadvantaged individuals can demonstrate they have made 

enforceable arrangements to permit one of them to vote the stock of all as a block without holding a

shareholder meeting. 

OR 

 ____ f) The disadvantaged individual(s) control the Board of Directors through actual

numbers of voting directors.

 ____ g) The disadvantaged individual(s) control the Board of Directors through weighted 

voting and such voting is permitted by applicable state law.

2. List the titles of all officers, directors, and key managers and the hours devoted by such individuals to

the management of the applicant business.

Name Title Hours

_____________________ __________ _______ 

_____________________ __________ _______ 

_____________________ __________ _______ 

_____________________ __________ _______ 

3. Is the CEO, President or any disadvantaged full-time manager engaged in or planning to engage in 

outside employment? ___ Yes ___ No. If yes, provide details as to the extent of outside employment

or other business dealings including daily hours of employment, location and explanation as to how 

this outside employment does not conflict with the ability to manage and control the daily operations 

of the applicant concern, provide as Attachment E-1.

4. Have any of the nondisadvantaged individuals involved in the management of the applicant firm,

and/or stockholders, officers, directors or their immediate family members, had a prior business 

relationship with any individual claiming disadvantaged status? This includes such relationships as

employer-employee, supervisor-employee, co-workers, investor-employee, etc. ___ Yes ___ No. If

yes, identify the person(s) and the type of business relationship, provide as Attachment E-2.

5. Does any nondisadvantaged individual receive compensation in any form, including dividends, as a 

director, officer, or employee that exceeds the compensation received by the disadvantaged President 

or CEO? ____ Yes ____ No. If yes, provide the total compensation received by the President or CEO,

and the name(s) and the amount of the total compensation paid to the nondisadvantaged

individual(s). If any nondisadvantaged individual is more highly compensated, provide a statement 

that justifies the need for the nondisadvantaged individual(s) to receive a higher compensation,

provide as Attachment E-3.

6. Does the applicant firm operate in an industry that requires bonding or professional licenses?

___ Yes ___ No. If yes, identify the qualifying individual(s) for the critical licenses, general

indemnity agreement, permits, certifications, and bonding required to operate the applicant firm, 

provide as Attachment E-4.

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 7
7. List the names and titles of all individuals who have access to the firm’s bank account.

 Name Title 

 ________________________ _______________________ 

 ________________________ _______________________ 

 ________________________ _______________________

 ________________________ _______________________

 ________________________ _______________________

8. Do any individual, (other than the individual(s) claiming disadvantaged status) or entities provide: 

a) Financial support to the applicant firm ___ Yes ___ No

b) Subcontracts, Joint Ventures or Teaming Arrangements ___ Yes ___ No

c) Office space (rent or leased) ___ Yes ___ No

d) Equipment (rent or leased) ___ Yes ___ No

e) Employees (other than from employment agencies) ___ Yes ___ No 

If you answered yes to any of the above, please provide specific details (i.e., names, titles, copies of

agreements, leases, etc.) of such arrangements, provide as Attachment E-5. 

 

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations) 8
Each person signing below: 

1. Certifies that the information provided with regard to my social and economic disadvantaged

status is true, accurate and complete to the best of my knowledge and belief.

2. Certifies that the information provided with regard to my ownership and control status is true,

accurate and complete to the best of my knowledge and belief.

3. Certifies that the information provided with regard to my status as a United States citizen is true,

accurate and complete to the best of my knowledge and belief.

4. Certifies that the information provided with regard to my individual disadvantaged status is true,

accurate and complete to the best of my knowledge and belief.

5. Certifies that the information provided, including that shown on documents accompanying this

application, is true, accurate and complete to the best of my knowledge and belief.

6. Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state

and local agencies to determine violations of law.

7. Acknowledges that EPA’s approval of an application does not affect the Government’s right to

pursue criminal prosecution for incorrect or incomplete information given on the application

form, even if correct information has been included in other materials submitted to EPA.

Name SSN Date 

________________________ _______________________ ______________________ 

________________________ _______________________ ______________________ 

________________________ _______________________ ______________________ 

________________________ _______________________ ______________________ 

________________________ _______________________ ______________________ 

The public reporting and recordkeeping burden for this collection of information is estimated to average 1 

hour per response. Send comments on the Agency's need for this information, the accuracy of the 

provided burden estimates, and any suggested methods for minimizing respondent burden, including 

through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. 

Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. 

Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA DBE Certification Application (EPA Form 6100-1d) 

(Corporations)

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