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AFFIRMATIVE ACTION QUESTIONNAIRE
This Form must be fully completed or your bid will be disqualified.
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COMPANY NAME
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MAILING ADDRESS CITY/STATE ZIP CODE
PLANT OR BUSINESS LOCATION (IF DIFFERENT FROM ABOVE)
______________________________________ ________________________________
CONTACT PERSON TELEPHONE NUMBER
EMPLOYER IDENTIFICATION NUMBER AS ISSUED BY IRS OR PERSONAL SOCIAL SECURITY NUMBER OF AN OWNER __ __ __ __ __ __ __ __ __
Is this company a minority or woman owned business? _________________
The owner is Black __ Hispanic __ American Indian __ Asian __ Other __ Woman __
Indicate the number of employees (check one)
1 – 5 ____ 41 – 50 ____
6 – 10 ____ 51 – 100 ____
11 – 20 ____ 101 – 150 ____
21 – 30 ____ 151 – 200 ____
31 – 40 ____ Plus-200 ____
IT IS UNDERSTOOD THAT THE CITY’S CIVIL RIGHTS ORDINANCE 930612 REQUIRE ANALYSIS: AFFIRMATIVE ACTION PROGRAM SUBMISSION (CIVIL RIGHTS ORDINANCE, CODE OF GENERAL ORDINANCES, CITY OF KANSAS CITY, MO.) BY A PROVIDER OF GOODS AND SERVICES TO THE CITY, AND UNLESS THIS REQUIREMENT IS COMPLIED WITH, SAID PROVIDOR SHALL BE LIMITED TO A TOTAL AMOUNT OF $52,000.00 FOR SALES AND/OR SERVICES TO THE CITY IN THIS AND THE NEXT PRECEDING FISCAL YEAR.
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SIGNATURE TITLE
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