PENNSYLVANIA DEPARTMENT OF TRANSPORTATION BUREAU OF PROJECT DELIVERY ATTENTION: PREQUALIFICTION OFFICE 400 NORTH STREET 7TH FLOOR NORTH – HARRISBURG, PENNSYLVANIA 17120 CONFIDENTIAL -PART 3 CONTRACTOR’S AFFIRMATIVE ACTION STATEMENT NOTE: All requested information must be submitted in the format displayed on this form. The Department will not accept any substitute submission of the requested information. This form must be completed in total. Name of Company ______________________________________________________ Equal Employment Policy Officer ___________________________________ Date Submitted __________________________________________________ Business Partner Registration No. ______________________________________ Act 89 of 2013 amended Section 303 of Title 74 of the Pennsylvania Consolidated Statutes to ensure that contracting entities maximize the participation of Diverse Businesses (DBs). All contractors that are certified as Disadvantaged Business Enterprises (DBEs) by the Pennsylvania Unified Certification Program are also recognized as DBs. Other DBs include minority-owned businesses, women-owned businesses, veteran-owned small businesses, and service-disabled veteran-owned small businesses; but these DBs must be certified by an appropriate third-party certifying organization. Please indicate the declaration that describes your organization’s status: My organization is certified by a certifying organization that is recognized as a DB under Act 89. Evidence of the validity of this certification is attached to this Affirmative Action Statement. My organization is not certified by a certifying organization that is recognized as a DB under Act 89. For Department use only: Accepted by: _______________________________ Signature/Title Date
PENNSYLVANIA DEPARTMENT OF TRANSPORTATION BUREAU OF PROJECT DELIVERY ATTENTION: PREQUALIFICTION OFFICE 400 NORTH STREET – 7TH FLOOR NORTH HARRISBURG, PENNSYLVANIA 17120 CONFIDENTIAL -PART 3 CONTRACTOR’S AFFIRMATIVE ACTION STATEMENT NOTE: All requested information must be submitted in the format displayed on this form. The Department will not accept any substitute submission of the requested information. This form must be completed in total. Name of Company ______________________________________________________ Equal Employment Policy Officer ___________________________________ Date Submitted __________________________________________________ Business Partner Registration No. ______________________________________ Act 89 of 2013 amended Section 303 of Title 74 of the Pennsylvania Consolidated Statutes to ensure that contracting entities maximize the participation of Diverse Businesses (DBs). All contractors that are certified as Disadvantaged Business Enterprises (DBEs) by the Pennsylvania Unified Certification Program are also recognized as DBs. Other DBs include minority-owned businesses, women-owned businesses, veteran-owned small businesses, and service-disabled veteran-owned small businesses; but these DBs must be certified by an appropriate third-party certifying organization. Please indicate the declaration that describes your organization’s status: My organization is certified by a certifying organization that is recognized as a DB under Act 89. Evidence of the validity of this certification is attached to this Affirmative Action Statement. My organization is not certified by a certifying organization that is recognized as a DB under Act 89. For Department use only: Accepted by: _______________________________ Signature/Title Date
New-Subcontractor-Application.docx