### Environmental Protection Agency

EPA DBE Certification Application For a Minority Business Enterprise (MBE) /Women-owned Busin ess Enterprise (WBE) Under EPA’s Disadvantaged Busi ness Enterprise (DBE) Program **Alaska Native Corporation (ANC) Owned Concern**
Name of Alaska Native Corporati on (ANC): _______________________________________________
Address of ANC: ______________________________________________________________________
Name of Pres ident/CEO: __________________________________ EIN: _________________________ E-mail Address:_________________________________________ Business Address:______________________________________________ County:_______________ City:_________________________________ State:_______________ Zip Code:__________________
Phone Numb er:___________________________ Fax Number :________________________________ Mailing Address (if different than above): ________________________ County:_________________ City:_________________________________ State:_______________ Zip Code:__________________ What is the firm’s 4-digit pr imary North American Industrial Classification (NAIC) code?

_____________________________________________________________________________________ Is your firm certified by the Small Business Ad ministration under its 8(a) Business Development Program?___ Yes ___ No. If yes, provide Pro-Net number: _________________________________ Is your firm certified by the Small Busine ss 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 nu mber(s): ________________________________________________ Is your firm certified by a St ate 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 certificati on by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide explanat ion/documentation:__________________________________________________

_____________________________________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1e) (Alaska Native Corporations) OMB Control No: 2090-0030 Approval Expires: XX/XX/XXDo you have any other certification as a disadvantaged business entity, i.e., MBE, DBE, WBE, etc? ___Yes __

**_**No. If yes, provide Stat e(s) and ID nu mber(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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# Busine **ss Eligibility SECTION A**  **Social Disadvantage**

1

. A n A l a s ka Na tive Corpora t ion tha t tha t m eets the f o llowing criteria is consid ered socia lly di s a dvan tag e d:
A l a s ka Na tive Corpora t ion or A N C mea n s a n y Regiona l Corpora t ion, Villa ge Corpora t ion, U r ba n C o r p or a t ion, or Gr oup C o r p or a t ion or ga niz e d und e r the la ws of the S t a t e of A l a s ka in acco rdan ce w i t h t h e Al as k a N a t i ve Cl ai m s Set t l em en t Act , as am en ded (43 U.S.C. 1601, et seq. ).
Provide documenta t ion tha t the a pplica n t enti ty m eets th ese criteria as Attach m e n t A-1. 

# SECTION B
**Economic Disa dva**  **n ta**  **ge**

1

. Do A l a s ka Na tives a n d d e scend a nts of Na tives own a ma jority of both the tota l equity of the A N C a n d the tota l voting powers to e l e c t d i r e c t or s of the A N C thr o ugh the i r hold i ngs of s e t t l em en t co m m o n s t o c k ? ___ Y e s ___ N o . I f y e s , pro v i d e veri fi cat i o n o f t h e percen t a g e o f A l a s ka Na tive owne r s hip a s a tta c h me nt B

- 1

. 

# SECTION C

**Owne r**  **ship**

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. Doe s the A N C a n d hold e r s of its se ttle m e n t c o mmon stoc k own a t le a s t 5 1 % inte r e st in the A N C ? Ple a se pr ovid e d o c u me nta t ion a s a tta c h me nt C

- 1

. 2

. If mor e tha n one c l a ss of stoc k, pr ovid e inf o r m a t ion f o r e a c h c l a ss: V o t i n g N o n - T o t a l Voting a) To t a l n u m b er o f s h ares au t h o r i z ed:

_____ ______ _____ b) To t a l n u m b er o f s h ares cu rren t l y o u t s t a n d i n g :
_____ ______ _____ 3. Li s t al l en ti ti es , i n di vi dual s , an d/ o r trus ts tha t ha ve a n owne r s hip inte r e st in the a pplic a n t firm

. N a m e T i t l e O w n e r s h i p P e r c e n t V o t i n g N o n - v o t i n g T o t a l

___________________________ ____________________ ______ _________ ______

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1e ) (A la sk a Na t i v e C o rp ora t i o n s ) 

### 34. H a ve t h ere been an y ch an g e s i n o w n e rs h i p i n t h e l a s t y e ar? ___ Y e s ___ N o . I f y e s , di d owne r s hip a f f e c t the d i sa d v a n ta ge d sta t us of your f i r m ? Ple a se e x pla i n a s A tta c h me nt C

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. 

# SECTION D **Contr o**  **l a nd Ma**  **na ge**  **me nt** 

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. A r e the ma na gement a n d d a ily business opera t ions of the a pplica n t f i rm controlled by the A N C thr o ugh one or mor e d i sa d v a n ta ge d ind i vid u a l members who possess suf f i cient ma na ge me nt e x pe r i e n c e of a n e x te nt a n d c o mple x i ty to r u n the c onc e r n ? ___Y es ___N o. If ye s, pr ovid e d o c u me nta t ion to ve r i f y tr iba l me mbe r ship a n d ma na ge me nt c o mpe t e n c y a s A tta chment D- 1

. 2

. A r e me mbe r s of the ma na ge me nt te a m , busine ss c o mmitte e me mbe r s, of f i c e r s , a n d d i r e c t or s e n ga ge d in a n y outsid e e m ployme nt or othe r busine ss inte r e sts whic h c onf lic t with the m a n a g e m e n t o f t h e appl i c an t fi rm ? ___ Y e s ___ N o
. 3

. L i st the title s of a ll of f i c e r s , d i r e c t or s, ma na ge me nt me mbe r s, pa r t ne r s a n d ke y ma na ge r s a n d th e h o u rs devo ted, by s u ch i n di vi dual (s ) to the ma na gement of the a pplica n t f i rm.
N a m e T i t l e H o u r s

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________ 4. L i st the na me s of a ll ind i vid u a l s who ha ve a c c e ss to the f i r m ’s ba nk a c c o unt.
N a m e T i t l e

___________________________ __________________________

**__________________________ __________________________** 

**__________________________ __________________________**

**__________________________ __________________________**

E P A D B E Ce r t if

icatio n A ppl icatio n ( E P A F o r m 6100- 1e ) (A la sk a Na t i v e C o rp ora t i o n s ) 

### 4**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 econom**  **ic disadvantaged status is true, accurate, and co**  **mplete 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 Federa**  **l, state and local agencies to determine violations of law.** 
**6. Acknowledges that EPA’s approval of an application does not affect the Govern**  **ment’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 materi**  **als submitted to**  **EPA.**
Name SSN Date

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________ The public reporting a nd recordkeeping burden for this collection of information is estima ted to average 1 hour per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and a ny 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 (28 22 T), 1 20 0 Pennsylvania Ave., NW, Wa shington, D.C. 204 60. Include the OMB control number in any correspondence. Do not send the completed form to this a ddress

EPA DBE Certification Application (EPA Form 6100-1e) (Alaska Native Corporations) 

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