COLORADO DEPARTMENT OF TRANSPORTATION Civil Rights ...
COLORADO DEPARTMENT OF TRANSPORTATION
FINANCIAL INSTITUTION AUTHORIZATION
Civil Rights & Business Resource Center 4201 East Arkansas Avenue, Rm. 150 Denver, Colorado 80222 303 512-4140, FAX 303 952-7091
THIS FORM MUST BE COMPLETED AND MUST ACCOMPANY YOUR COMPLETED APPLICATION
DBE Applicants: Complete and sign this section only, then have your financial institution complete the remainder. This form is part of your application and must be returned with it, fully completed.
Dear _______________________________________________ :
(name of financial institution)
I have authorized the Civil Rights & Business Resource Center to seek information about my firm's relationship
with your company.
Please complete this form. My application for DBE Certification will not be considered complete unless I return this form with my DBE application.
L Thank you. IA Name of Firm
Printed Name of Owner/President
Owner/President's Signature
Date
T TO BE COMPLETED BY THE FINANCIAL INSTITUTION
N 1.
Indicate the services your institution provides to this company:
E a) Checking accounts:
T Payroll
Number of authorized signatures:_____
T Regular Number of authorized signatures:_____
ID T Other
Number of authorized signatures:_____
Identify "Other" accounts: _____________________________________________________________
F b) List the names of authorized signers according to account type:
N _____________________________________________________________________________________
_____________________________________________________________________________________
CO 2. List any outstanding commercial/business loans:
Origination
Original
Current
Collateral
Date
Amount
Balance
(if secured)
a) Are there personal guarantors for any of the loans? T Yes
T No
If yes, list their names:______________________________________________________________________
Page 1 of 2 CDOT Form #1308 1/13
3. Does the company have a line of credit?
T Yes
T No
a) Is it secured? T Yes
T No
List the collateral:___________________________________
L ________________________________________________________________________________________
IA ________________________________________________________________________________________
b) Are there personal guarantors? T Yes
T No
T If yes, list their names:______________________________________________________________________
N 4. List the names of all company individuals who signed promissory notes: E ________________________________________________________________________________________
ID Name of Financial Institution
Address
City
State
Zip
F Printed name of bank official
Title
N Signature
Date
CO Page 2of 2 CDOT Form #1308 1/13
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