Environmental Protection Agency

EPA DBE Certification Application 

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

Under EPA’s Disadvantaged Business Enterprise (DBE) Program 

Alaska Native Corporation (ANC) Owned Concern

Name of Alaska Native Corporation (ANC): _______________________________________________ 

Address of ANC: ______________________________________________________________________ 

Name of President/CEO: __________________________________ 

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? 

_____________________________________________________________________________________ 

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 and 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 explanation/documentation:__________________________________________________ 

_____________________________________________________________________________________ 

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

(Alaska Native 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): ________________________________ 

Is the applicant ANC business corporation a for profit corporation? ___ Yes ___ No. 

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

(Alaska Native Corporations) 

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Business Eligibility 

SECTION A 

Social Disadvantage 

1. An Alaska Native Corporation that that meets the following criteria is considered socially 

disadvantaged: 

 

Alaska Native Corporation or ANC means any Regional Corporation, Village Corporation, 

Urban Corporation, or Group Corporation organized under the laws of the State of Alaska in 

accordance with the Alaska Native Claims Settlement Act, as amended (43 U.S.C. 1601, et seq.). 

Provide documentation that the applicant entity meets these criteria as Attachment A-1. 

SECTION B 

Economic Disadvantage 

1. Do Alaska Natives and descendants of Natives own a majority of both the total equity of the 

ANC and the total voting powers to elect directors of the ANC through their holdings of

settlement common stock? ___ Yes ___ No. If yes, provide verification of the percentage of

Alaska Native ownership as attachment B-1.

SECTION C 

Ownership 

1. Does the ANC and holders of its settlement common stock own at least 51% interest in the

ANC? Please provide documentation as attachment C-1. 

2. 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: _____ ______ _____ 

3. List all entities, individuals, and/or trusts that have an ownership interest in the applicant 

firm. 

Name Title Ownership Percent

 Voting Non-voting Total

___________________________ ____________________ ______ _________ ______ 

___________________________ ____________________ ______ __________ ______ 

___________________________ ____________________ ______ __________ ______ 

___________________________ ____________________ ______ __________ ______ 

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

(Alaska Native Corporations) 

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

ownership affect the disadvantaged status of your firm? Please explain as Attachment C-2. 

SECTION D 

Control and Management 

1. Are the management and daily business operations of the applicant firm controlled by the 

ANC through one or more disadvantaged individual members who possess sufficient 

management experience of an extent and complexity to run the concern? ___Yes ___No. If 

yes, provide documentation to verify tribal membership and management competency as

Attachment D-1.

2. Are members of the management team, business committee members, officers, and directors 

engaged in any outside employment or other business interests which conflict with the

management of the applicant firm? ___ Yes ___ No. 

3. List the titles of all officers, directors, management members, partners and key managers and

the hours devoted, by such individual(s) to the management of the applicant firm. 

Name Title Hours

 ____________________________ _______________________________ __________ 

 ____________________________ _______________________________ __________ 

 ____________________________ _______________________________ __________ 

 ____________________________ _______________________________ __________ 

4. List the names of all individuals who have access to the firm’s bank account.

Name Title

 ___________________________ __________________________ 

 __________________________ __________________________ 

__________________________ __________________________

 __________________________ __________________________

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

(Alaska Native Corporations) 

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Each person signing below: 

1. Certifies that the applicant firm is at least 51% owned and controlled by an Alaska Native

Corporation (ANC).

2. Certifies that the information provided with regard to the applicant firm’s economic

disadvantaged status is true, accurate, and complete to the best of his/her knowledge and

belief.

3. Certifies that the information provided with regard to the applicant firm’s ownership and

control status is true, accurate, and complete to the best of his/her knowledge and belief.

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

this application, is true, accurate, and complete to the best of his/her knowledge and belief.

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

state and local agencies to determine violations of law.

6. 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 6100-1e) 

(Alaska Native Corporations) 

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