Apply for Your Diversity Certificate

Show Pride in your Diverse Workforce and Open the Door to More Business!

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To begin the application process, please fill out the following form. Your information will be emailed to our office for review. All fields on the form below are required.

Name of Business:

Physical Address of Main Office:

City:

State:

Zipcode:

Name of Authorized Representative:

Title of Authorized Representative:

Representative Contact Email:

Representative Contact Phone:

Representative Contact Fax:

Date Business began Operations:

MM/DD/YYYY

Number of Full Time Employees:

* employed full time as of date of application

Number of Diverse Individuals:

* employed full time as of date of application

"Diverse Individuals" means:

"Black Americans" (persons having origins in any of the black racial groups of Africa)
"Hispanic Americans" (persons of Mexican, Puerto Rican, Cuban, Dominican, Central or South American, or other Spanish or Portuguese culture or origin)
"Native Americans" (persons who are American Indians, Eskimos, Aleuts, or native Hawaiians)
"Asian-Pacific Americans" (persons whose origins are from Japan, China, Taiwan, Korea, Burma (Myanmar), Vietnam, Laos, Cambodia (Kampuchea), Thailand, Malaysia, Indonesia, the Philippines, Brunei, Samoa, Guam, the U.S. trust territories of the pacific islands (Republic of Palau), the Commonwealth of the northern Marianas islands, Macao, Fiji, Tonga, Kiribati, Juvalu, Nauru, Federated states of Micronesia, or Hong Kong)
"Subcontinent Asian Americans" (persons whose origins are from India, Pakistan, Bangladesh, Bhutan, the Maldives islands, Nepal or Sri Lanka)
"Women"
"Physical or Mental Disability" (persons having a physical or mental impairment that substantially limits one or more major life activities, a record of such impairment, or being regarded as having such impairment)

Is at least 51% of the business owned by one or more Diverse Individuals as defined in numbers 1 - 7 above? Yes No

If yes, number of Diverse Individuals who own the 51% of the business:

Is the business management and daily business operations controlled by one or more Diverse Individuals defined in numbers 1 - 8 above, who own at least 51% of the business? Yes No

If the business is a corporation, is 51% of the stock owned by one or more Diverse Individuals defined in numbers 1 - 8 above? Yes No

Is the business comprised of 75% or more Diverse Individuals as defined in numbers 1 - 8 above? Yes No

Acknowledgement

The undersigned authorized representative of the Applicant business hereby represents the information contained in this Application is true and accurate, subject to the laws of perjury in the state wherein the Application is signed.

While DCS does not guarantee the accuracy of the information submitted to us by the applicant, DCS will conduct an examination of the portions of the application we deem to be significant, to verify that the applicant meets our diversity criteria and that the essential facts in the application are true.

By clicking the "Submit" button, you are signing this document electronically and accept all responsibility for the accuracy of the information provided. You may be asked for a physical signature at a later date.