17._CCHCS-MC-333-_Bidder_Certification.pdf

Proposal Number: SD23-00094

CCHCS-MC-333 Rev. 08/17/2017

BIDDER CERTIFICATION

This form must be submitted with your bid. Failure to do so may be cause for your bid to be disqualified. If you have obtained certification status as a Small/Micro Business Enterprise from the Department of General Services (DGS) and fail to complete this section, your business may be classified as a large business, which will preclude your bid from receiving the five percent (5%) Small/Micro Business Preference.

BUSINESS STATUS:

I am a DGS certified Small Business Enterprise. My Certification number is: ___________________.

I am a DGS certified Microbusiness Enterprise. My Certification number is: ___________________.

I am a large business seeking the Non-Small Business Subcontractor Preference.

I am a large business.

By virtue of submitting this form, the undersigned is certifying under penalty of perjury that they are the duly authorized representative accepting the terms and conditions expressed in this solicitation.

COMPANY NAME:

STREET ADDRESS: P.O. BOX:

CITY, STATE AND ZIP CODE: CITY, STATE AND ZIP CODE:

TELEPHONE NUMBER: FAX NUMBER:

FEDERAL ID or SOCIAL SECURITY NUMBER: EMAIL ADDRESS: (Address to be used on the matrix)

TAX STATUS: [ ] Individual/Sole Proprietor [ ] Estate or Trust [ ] Partnership

[ ] Corporation (State in which incorporated _____) [ ] Other: ___________________________

PRINT NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:

SIGNATURE OF AUTHORIZED REPRESENTATIVE: DATE: