DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM DBE TRUCK OWNER by onx77558

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									                                                                                                                                          Form 2104
                                                                                                                                          (Rev. 9/2005)
                                                  Texas Department of Transportation                                                      (GSD-EPC)
                                                                                                                                          Page 1 of 1
                                                      Construction Division - BOP Section
                                                                 125 E. 11th Street
                                                              Austin, TX 78701-2483
                                                     Office: 512/486-5530 Fax: 512/486-5539

                                         Texas Unified Certification Program (TUCP)
              DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM
                       DBE TRUCK OWNER-OPERATOR APPLICATION
                            Application must be completed and signed by the driver and owner of the truck

STATE OF
COUNTY OF
Before me, the undersigned notary public, personally came and appeared (PRINT NAME OF TRUCK OWNER-OPERATOR):


Federal Tax ID Number (Not SSN):                                                           Call IRS (1-800-829-4933) if Federal Tax ID Number is needed

TRUCK OWNER-OPERATOR ADDRESS:                                                                    CITY, STATE:

TRUCK OWNER-OPERATOR PHONE:                               /      -                           FAX NUMBER:                  /      -

PLEASE PROVIDE A COPY OF THE FOLLOWING DOCUMENTS:
         Commercial Drivers License                              Schedule C (Sole Proprietorship page) Tax Return
         Truck Vehicle Title                                     Personal Net Worth $
         Truck Vehicle Registration                              (Money available for personal use minus debt [excludes home and truck])
WHO, BEING FIRST SWORN BY ME, DID DEPOSE AND DECLARE:
Please CHECK the boxes that apply:
CITIZENSHIP:                                                  OTHER INFORMATION:
    U. S. Citizen                                               African-American                        Alaskan Native                GENDER:
    Lawfully Admitted Permanent Resident                        Hispanic                                Asian American                  Female
    Other (explain):                                            Native American                         Asian Pacific                   Male
                                                                Non-designated Group
I swear (or affirm) that the information provided by (print name of truck owner-operator)
is true and correct affecting eligibility requirements of the Texas Unified Certification Program (TUCP) DBE Program.

TRUCK OWNER-OPERATOR SIGNATURE:
The truck owner-operator understands that any material misrepresentation will be grounds for decertification and for
initiation of action under State or Federal laws concerning false statements.
                                                                  Privacy Statement
The Texas Department of Transportation maintains the information collected through this form. With few exceptions, you are entitled on request to be
informed about the information that we collect about you. Under §§552.021 and 552.023 of the Texas Government Code, you also are entitled to receive and
review the information. Under §559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect. For
inquiries call 866/480-2518.

Must be notarized by independent notary.
Sworn to and subscribed before me this                   day of                        ,            , at
                                                                                                                          (city, state)


                                                                                                (NOTARY) Signature
                    SEAL                                                                        Seal (if required)
                                                                                                My Commission Expires:
                                                  MAIL TO THE ABOVE ADDRESS

								
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