Submit completed form to smallbusiness@dot.state.fl.us

Firm Type (select only one option below):

Construction Firms and all other Non-Professional Services Firms

Professional Services

Firms must be registered in MyFloridaMarketPlace (MFMP) before the Department is able to add to the small business database. Information to register with MFMP is available here:

http://www.dms.myflorida.com/business_operations/state_purchasing/myfloridamarketplace

Please note: Completion of this form and listing on the small business site does not constitute Prequalification with FDOT.

Contractors who wish to become prequalified with FDOT in construction work classes should go to:

https://www.fdot.gov/contracts/prequal-info/prequalified.shtm

Consultants who wish to become prequalified with FDOT in Professional Services work types should visit: https://www.fdot.gov/procurement/prequalification.shtm

Business Name

Business Address

Street	City	State	Zip

Mailing Address

Street	City	State	Zip

Telephone	Other

Business Owner

E-mail	Date Business Established

Federal Employer Identification Number

FDOT Districts I am interested in performing work in: (Please check all that apply)

District 1	District 4	District 7
District 2	District 5	Turnpike
District 3	District 6	Central Office

I,	am an owner or duly authorized representative of

(Proposer/name of business), and I do hereby declare:

This business:

Meets the definition for a small business pursuant to Section 337.027, F.S.

Gross revenues, three year average (include affiliate businesses) $

Pursuant to Section 337.027, F.S., a small business means a business with yearly average gross receipts of less than $25 million for road and bridge contracts and less than $10 million for professional and nonprofessional services contracts. A business’ average gross receipts is determined by averaging its annual gross receipts over the last three years, including the receipts of any affiliates as defined in Section 337.165, F.S.

The undersigned hereby authorize(s) and request(s) any person, firm or corporation to furnish any pertinent information requested by the State of Florida Department of Transportation deemed necessary to verify the statements made in this affidavit or regarding the ability, standing and general reputation of the Proposer. I declare, under penalty of perjury, that the information provided above and any supporting documents are true and accurate to the best of my knowledge. By submittal of the Affidavit certification, you are affirming that your firm meets the definition for a small business, pursuant to s. 337.027, F.S. It is the responsibility of the owner/authorized representative to inform the Department within 30 days of any change that would affect your small business eligiblity, including average gross revenues over the prior three years exceeding the small business size threshold. Changes that would affect eligibility should be communicated to smallbusiness@dot.state.fl.us. This certification is good for one year or until your firm exceeds the small business threshold, whichever is earlier. To ensure regulatory compliance and accountability for the Business Development Initiative program, firms agree to furnish any pertinent information to verify the statements in this Small Business Affidavit Certification, upon request by the Department. If financial documents are not timely provided within 10 business days, or financial documents do not confirm small business eligibility, the Department reserves the right to revoke this small business certification.

_______________________________________________________________

Owner/Authorized Representative Signature	Date

Owner/Authorized Representative Printed Name & Title

Notary:

STATE OF ____________________________

COUNTY OF __________________________

Before me, the above signed authority, personally appeared _____________________________, who is personally known to me or has produced __________________________ (type of identification) identification and is duly sworn, deposes and says that he/she is authorized to represent ___________________________ (business). Sworn and subscribed to before me this __________ day of ______________________, _________.

_____________________________________________________	________________________

(Notary Signature)	My Commission Expires: