California Code of Regulations › Title 2 - Administration › Division 2 - Financial Operations › Chapter 4 - Office of the State Treasurer › Subchapter 4 - Target Business Enterprise Participation Goals for Professional Bond Services › Article 4 - Negotiated Sales › Appendix A - State of California Office of the State Treasurer Application for Target Business Enterprise Certification

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This is the official application form for certification
						as a "Target Business Enterprise" with the Office of the State Treasurer of the
						State of California. Under the regulations adopted by the State Treasurer, a
						"Target Business Enterprise" includes all minority business enterprises (MBEs),
						women-owned business enterprises (WBEs) and disabled veteran business
						enterprises (DVBEs).
Instructions:
Please review the applicable
						statutes and regulations. Answer all questions carefully. If a question does
						not apply to your firm or circumstances, please enter "NA."
___________________________
1. Name of Firm
Home Office Address __________(No.)
						______________________________(Street)
						_____________________________________________(City) _______________(State)
						_______________(Zip)
Telephone Number(s)
						________________________________________(Area Code and No.)
						______________________________(Telefax No.)
California address (if different)
						__________________________________________________(Number)
						______________________________________________________________________(Street)
__________________________________________________(City)
						__________________________________________________(Zip)
California Telephone Number(s)
						__________________________________________________(Area Code and No.)
						__________________________________________________(Telefax No.)
2. Name of Firm President/ Chief Executive Officer/
						Managing Partner.
______________________________(First Name)
						_______________(M.I.) __________________________________________________(Last
						Name) ____________________(Title)
3. Name and title of person completing this
						application.
______________________________(First Name)
						_______________(M.I.) __________________________________________________(Last
						Name) ____________________(Title)
4. This firm is applying for certified status as (check
						all that apply):
__________ Minority-owned Business (MBE).
__________ Women-owned Business (WBE).
__________ Disabled Veteran-owned Business (DVBE).
5. For MBE Applicants Only.
(a) Please indicate the ethnicity of the firm's Principal
						Owner(s). (check all that apply):
___________________________
American Indian/Native American
___________________________
Filipino
___________________________
Asian
___________________________
Hispanic
___________________________
Black/African-American
___________________________
Other (specify)___________________________
(b) Please indicate the percentage of the firm's stock or
						partnership interest owned by each of the ethnic groups identified as Principal
						Owners in Question 5 (a), above:
___________________________
%
American Indian/ Native American
___________________________
%
Black/ African American
___________________________
%
Hispanic
___________________________
%
Asian
___________________________
%
Filipino
___________________________
%
Other (specify)___________________________
(c) Is the management and control of the daily operations
						of the firm in accordance with the division of ownership/partnership interests
						as specified in (b)?
___ Yes
___ No (Please explain).
___________________________
___________________________
6. For WBE Applicants Only.
(a) Please indicate the percentage of the firm's stock or
						partnership interest owned by the following:
___ % -- Female Ownership/Partnership.
___ % -- Male Ownership/Partnership.
(b) Is the management and control of the daily operations
						of the firm in accordance with the division of ownership/partnership interests
						as specified in (a) ?
___ Yes
___ No (Please explain).
___________________________
___________________________
7. For DVBE Applicants Only
(a) Are the owner(s) of this firm resident(s) of the
						State of California?
___________________________
Yes
___________________________
No
(b) Do the owner(s) of this firm have a disability rating
						as issued by either the U.S. Department of Veterans Affairs or the Department
						of Defense?
___________________________
Yes**
___________________________
No
**
If yes, please attach award letter from
								the federal agency indicating the existence of a service-connected disability
								at the time this application is submitted to the Office of the State
								Treasurer.
(c) Please indicate the percentage of the firm's stock or
						partnership interest owned by the disabled veteran owner(s).
___ % Ownership/Partnership
(d) Are the management and control of the daily
						operations of the firm in accordance with the division of ownership/partnership
						interests as indicated in Question 7 (c), above?
___ Yes
___ No (please explain).
___________________________
___________________________
8. Identify the specific type(s) of Professional Bond
						Services that the firm provides (check all that apply):
___________________________
Underwriting
___________________________
Bond Counsel
___________________________
Financial Advisor
___________________________
Underwriter's Counsel
___________________________
Investment Advisor
___________________________
Other (please provide specific description
								below)
___________________________
9. If licensing or accreditation is required to conduct
						the firm's business, please complete this item:
Type of License/
Accreditation
Issued By
Date
Issued
Expiration
Date
Holder/Registrant
of
								License
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
10. Certification Eligibility.
(a) If your firm seeks certification as a "minority
						business enterprise," by submitting this application you certify that your firm
						qualifies under the following statutory definition:
"Minority business enterprise"
means a
						business concern that meets all of the following requirements:
(1) A sole proprietorship owned by a minority or a firm
						or partnership, 51 percent of the stock or partnership interests of which are
						owned by one or more minorities.
(2) Managed by, and the daily business operations are
						controlled by, one or more minorities.
(3) A sole proprietorship, corporation, or partnership
						with its home office located in the United States, which is not a branch or
						subsidiary of a foreign corporation, firm, or other business.
(b) If your firm seeks certification as a "women business
						enterprise," by submitting this application you certify that your firm
						qualifies under the following statutory definition:
"Women business enterprise"
means a business
						concern that is
all
of the following:
(1) A sole proprietorship owned by a woman or a firm or
						partnership, 51 percent of the stock or partnership interests of which are
						owned by one or more women.
(2) Managed by, and the daily business operations are
						controlled by, one or more women.
(3) A sole proprietorship, corporation or partnership
						with its home office located in the United States, which is not a branch or
						subsidiary of a foreign corporation, firm, or other business.
(c) If your firm seeks certification as a "disabled
						veteran business enterprise," by submitting this application you certify that
						your firm qualifies under the following statutory definition:
"Disabled veteran business enterprise"
means
						a business concern that meets
all
of the following
						requirements:
(1) A sole proprietorship owned by a disabled veteran, or
						a firm or partnership, 100 percent of the stock or partnership interests of
						which are owned by one or more disabled veterans.
(2) Managed by, and the daily business operations are
						controlled by, one or more disabled veterans.
(3) A sole proprietorship, corporation, or partnership
						with its home office located in the United States, which is not a branch or
						subsidiary of a foreign corporation, firm, or other business.
11. Fraudulent Representations, Acknowledgements and
						Verification.
(a) In accordance with Section
						16857 of
						the Government Code, a person or firm that willfully and knowingly makes any
						false statements or misrepresentations in an Application for certification as a
Minority Business Enterprise or Women Business Enterprise
shall be
						liable for:
(1) Civil penalty not to exceed $5,000 (for the first
						violation) and up to $20,000 for each additional or subsequent violation;
						and
(2) Suspension from bidding on, or participating as
						either a contractor or subcontractor in, any professional bond services
						contract awarded by the state for a period of not less than 30 days nor more
						than one year. For an additional or subsequent violation of this section, the
						period of suspension shall be extended for a period of three years. A person or
						firm that fails to satisfy any of the penalties imposed for violations of this
						section shall be prohibited from further contracting with the state until all
						penalties are satisfied.
THIS SUBSECTION DOES NOT APPLY TO APPLICANTS OR
						APPLICATIONS FILED WITH THE TREASURER FOR CERTIFICATION AS A DISABLED VETERAN
						BUSINESS ENTERPRISE. HOWEVER, IN ADDITION TO ANY CRIMINAL PENALTIES PROVIDED
						FOR BY LAW, THE MAKING OF ANY FALSE STATEMENTS OR MISREPRESENTATIONS IN AN
						APPLICATION FOR CERTIFICATION AS A DISABLED VETERAN BUSINESS ENTERPRISE WILL BE
						GROUNDS FOR TERMINATING ANY CONTRACTS AWARDED TO THAT APPLICANT BY THE
						TREASURER AND MAY RESULT IN THAT APPLICANT'S DISQUALIFICATION FROM
						PARTICIPATING IN FUTURE CONTRACTS AWARDED BY THE TREASURER.
(b) Applicant agrees to submit additional information
						upon request of the Treasurer and acknowledges that the Treasurer may deny the
						application for certification from an Applicant as a Target Business Enterprise
						(MBE, WBE, or DVBE) if the additional information is not submitted in writing
						within 30 days after it is requested by the Treasurer.
(c) The Applicant consents to inspection of its books,
						records and other relevant business documents and to interviews of its
						principals and employees by the Treasurer or the Treasurer's representatives
						for the purpose of determining whether the Applicant is, or continues to be, an
						eligible TBE. The Applicant acknowledges that its application may be
						immediately denied or certification revoked if such inspection or interviews
						are refused or if the Treasurer determines, as a result of the inspection or
						interviews, that the Applicant does not qualify as a TBE.
(d) The Applicant agrees to provide to the Treasurer
						(with or without prior request of the Treasurer) information regarding any
						change in ownership or management and control of the Applicant's business
						within 30 days of the effective date of such change.
AFFIDAVIT
The Applicant has caused this application to be signed on
						its behalf by the undersigned, thereunto duly authorized.
___________________________
Applicant
By
___________________________
___________________________
Title
I certify (or declare) under penalty of perjury under the
						laws of the State of California that I have read this application and the
						exhibits thereto and know the contents thereof, and that the statements therein
						are true and correct.
Executed at ______________________________(Place), on
						____________________(Date), 19___.
________________________________________
(Signature)
NOTARY
On this ___ day of ______________________________ 19 ___,
						before me appeared ________________________________________(Name) to me
						personally known, who being sworn, did execute the foregoing affidavit, and did
						state that he/she was properly authorized by
						____________________________________________________________(Name of Firm) to
						execute the affidavit and did so as his/her free act and deed.
SEAL
NOTARY PUBLIC ______________________________
COMMISSION EXPIRES ______________________________
Mail completed application to:
TBE Program
Trust Services Division
State Treasurer's Office
P.O. Box 942809
Sacramento, CA 94209-0001