Name of the Company: 
 
Address: 
 
City, State, Zip code: 
 
Phone Number & Email: 
 
 
After careful consideration, I, the undersigned DBE owner or authorized designee, have elected not to apply 
or continue the firm's participation as a DBE at this time. This notice serves to inform the Virgin Islands 
Department of Public Works Unified Certification Program, of this decision.  
 
I understand that the firm is subject to decertification proceedings pursuant to Title 49, Code of Federal 
Regulations, Section 26.87, unless the reason for this decision is because the disadvantaged individual's 
Personal Net worth (PNW) exceeds the threshold of $1.32 million.  
 
Please mark which explanation best describes the reason(s) for voluntarily removing the firm from the DBE 
program: 
 
 
         Personal Net Worth Exceeds 1.32 million 
                            Change in Ownership                                 
 
 
         Sale of Business  
 
 
        
 
 
        No benefit in being certified as a  
 
 
 
 
 
 
                                       VIDPW DBE  
 
         Not interested in continuing participation in                                  Other: ________________________ 
         VIDPW DBE program  
 
 
 
The reasons stated: _____________________________________________________________________________ 
                            _____________________________________________________________________________ 
                            _____________________________________________________________________________ 
                            _____________________________________________________________________________ 
 
 
 
Authorization:        _____________________________________________________________________________ 
                                              (Print Name & Title) 
 
      ___________________________________________________ 
_____________________ 
                                               Signature                                                                   Date 
 
NOTICE OF VOLUNTARY REMOVAL 
FROM THE VIDPW DISADVANTAGED BUSINESS ENTERPRISE (DBE) PROGRAM 
SIGN