MADISON AREA TECHNICAL COLLEGE - SUPPLIER RELATIONS AND DIVERSITY

Diverse Business Utilization Program Application

PLEASE READ CAREFULLY - TYPE OR PRINT - ANSWER ALL QUESTIONS - ATTACH ADDITIONAL INFORMATION

Note - Business must be located in the State of Wisconsin to be considered for eligibility to participate in the Small
Disadvantaged Business Program.

Section I Principal Place of Business

Section II Certification/Eligibility
A. Submit the completed Small Disadvantaged Business Program Application and submit a current certification from
one of the following agencies and organizations. The certification must be valid for at least 90 days before
expiration:
1. [List of agencies and organizations TBD]
B. If certified, please provide:
Certifying Agency Name: ___________________________________________________
Type of Certification (i.e., MBE/WBE/SBE/DBE): __________________________________
Expiration Date:_________________________________________________
Attach copy of certification certificate.
C. Annual gross sales averaged over the previous three years:

MADISON AREA TECHNICAL COLLEGE - SUPPLIER RELATIONS AND DIVERSITY

Diverse Business Utilization Program Application
PLEASE READ CAREFULLY - TYPE OR PRINT - ANSWER ALL QUESTIONS - ATTACH ADDITIONAL INFORMATION

Note - Business must be located in the State of Wisconsin to be considered for eligibility to participate in the Small
Disadvantaged Business Program.
D. Please mark one of the following boxes that describes your Firm:
Professional Service Firm
General Service and Commodity Firm
Construction Service Firm
E. Number of Employees at all locations: ___________________
F. Provide three references:

Section III Race and Gender of Principal Owner (Please give an estimated percentage for race, please check one for
gender).
1. ___ % Asian American
___ % Hispanic American
___ % African American
2. ___ Female

___ % Native American

___ % White (Non-Hispanic)
___ % Other (Specify)
___ Male

Section IV Commodity
A. List all the products and services offered by your company.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Section V Business Type (Select the business type that applies to your business entity.)

Construction
Service Contractor
Commodities Supplier

Licensed Professional Services

Other _________________

Section VI Geographic Markets Serviced by Your Company

States
Counties
Other

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2

MADISON AREA TECHNICAL COLLEGE - SUPPLIER RELATIONS AND DIVERSITY

Diverse Business Utilization Program Application
PLEASE READ CAREFULLY - TYPE OR PRINT - ANSWER ALL QUESTIONS - ATTACH ADDITIONAL INFORMATION

Note - Business must be located in the State of Wisconsin to be considered for eligibility to participate in the Small
Disadvantaged Business Program.
Section VII Bonding Capacity: $________________

It is recognized and acknowledged that the statements contained in this application are true and that any material
misrepresentation will be grounds for denial of participation in the Madison Area Technical Colleges Diverse Business
Utilization Program. Misrepresentation may result forfeiture of awards or termination of contracts, which may be
awarded as the result of the information contained in this application.
I hereby authorize the Madison Area Technical College Office of Supplier Relations and Diversity to verify the accuracy of
the statements made in this APPLICATION in order to determine whether my company meets the requirements
established for participation in the Madison Area Technical College Diverse Business Utilization Program.

Signature

Print Name

Title

Date

Please submit this application and all additional documents to:

Madison Area Technical College
PO Box 14316
Madison, WI 53708-0316