City of Charlotte Contractor Development Program Enrollment Form

For questions, please contact us at ccdp@imwis.com or 888.717.3341.

Section 1 of 5 - Participant Information

Company Name

Business Mailing Address

Apartment # or Suite (If Applicable)

City

State

North Carolina

South Carolina

Georgia

Virginia

Florida

Zip Code

Contact Person

Phone Number

Cell Phone Number

Fax

Section 2 of 5 - Company Information

NIGP Code

NIGP Commodity Description

Type of Entity

Corporation

Partnership

Sole Proprietor

Date Business Established

Annual Business Volume ($)

Section 3 of 5 - Business Relationships

Do you currently have bonding?

Yes

Not applicable for type of business

Broker (If Applicable)

Surety (If Applicable)

Current Bond Capacity - Single ($) (If Applicable)

Current Bond Capacity - Aggregate ($) (If Applicable)

In the past three (3) years, I have BID on City of Charlotte projects as a:

Prime Contractor

Subcontractor

Both

None

In the past three (3) years, I have been AWARDED on City of Charlotte projects as a:

Prime Contractor

Subcontractor

Both

None

Section 4 of 5 - Certification, Ethnicity, and Union Information

What is the status of your City of Charlotte, Charlotte Business Inclusion Certification?

Active

Pending

Not started

Select all of the certifications that the business holds or for which the business is qualified to obtain:

Minority Business Enterprise (MBE)

Small Business Enterprise (SBE)

Women Business Enterprise (WBE)

Airport Concessionaire Disadvantaged Business Enterprise (ACDBE)

Disadvantaged Business Enterprise (DBE)

Historically Underutilized Business (HUB)

Certified With (Mark all that Apply):

City of Charlotte

North Carolina Department of Transportation

What is the ethnicity of the majority business owner?

Hispanic or Latino

Black or African American

Black, Indigenous, People of Color (BIPOC)

American Indian and Alaska Native

Asian

Native Hawaiian and Other Pacific Islander

Multiracial

White

Is your firm signatory to a union?

Yes

If you selected "Yes," which union?

Section 5 of 5 - Authorization

BY SUBMITTING THIS FORM YOU ARE AGREEING TO THE FOLLOWING:

I/WE AUTHORIZE AND CONSENT TO MERRIWETHER AND WILLIAMS INSURANCE SERVICES, INC. (MWIS), AS BOND ASSISTANCE PROGRAM ADMINISTRATORS, AND/OR SURETY/BANK OBTAINING INFORMATION FROM THIRD PARTIES, INCLUDING BUT NOT LIMITED TO, CREDITORS, BROKERS, SURETIES, INSURERS, BANKS, OR ANY INDIVIDUAL(S) OR INDIVIDUAL REPRESENTATIVE(S) OF ANY FIRM(S), ENTITY (IES) OR ORGANIZATION(S) RELATED TO THE EVALUATION OF MY/OUR QUALIFICATIONS. I/WE RECOGNIZE THAT TO ENSURE THE EFFECTIVENESS OF THE ENROLLMENT PROCESS, SUCH INDIVIDUALS MUST BE ABLE TO SPEAK FRANKLY AND OPENLY. ACCORDINGLY, I/WE HEREBY FULLY AND UNCONDITIONALLY RELEASE AND DISCHARGE THE PARTIES FROM ANY CLAIM OR LIABILITY RELATING TO INFORMATION PROVIDED IN CONNECTION WITH THE PROCESSING, INVESTIGATION AND EVALUATION OF OUR APPLICATION OR ENROLLMENT DOCUMENTATION.