Attachment X1_Phase 1 - VITAL Eligibility_4-18.pdf

Solicitation: 36C10X24R0026 Attachment X1 VITAL Eligibility Form

Offeror Name:

1. VITAL Viability Submission - Cover Page

Primary POC Name:

Primary POC Phone Number:

Primary POC Email Address:

Submitting As (select one): ☐ SDVOSB (complete A. below) ☐ Joint Venture (complete B. below)

A. If SDVOSB, A Business Name:

UEI #:

Address:

Check as applicable:

☐ Currently registered in SAM and small under NAICS 541611 (verifiable through SAM Reps and Certs) ☐ Veterans Small Business Certification (SBA VetCert Certified) as SDVOSB or currently seeking certification (complete VITAL Viability Submission Eligibility Supplemental if not yet eligible but seeking to become eligible).

If Joint Venture (JV), B

Separate Legal Entity Name:

UEI #:

Managing Venturer (or Protégé) /UEI #:

JV Partner Name / UEI #:

Check as applicable. My JV is the following:

☐ Small-Small JV

• ☐ Both partners currently registered in SAM and small under NAICS 541611 (verifiable through SAM Reps and Certs)

• ☐ Managing venturer currently certified in SBA VetCert as an SDVOSB

☐Mentor-Protégé (M-P)

• Is M-P agreement approved by SBA? Yes ☐ No ☐

• ☐ Protégé currently registered in SAM and small under NAICS 541611 (verifiable through SAM Reps and Certs)

• ☐ Protégé currently certified by SBA in VetCert as an SDVOSB

☐ JV managing venturer or Protégé is not yet SBA VetCert Certified but has started the certification process (complete VITAL Viability Submission Eligibility Supplemental if not yet eligible but seeking to become eligible).

(See next page for Eligibility Supplemental)

2. VITAL Viability Submission – Eligibility Supplemental If NOT registered in SAM or SBA VetCert Certified, or no SBA approved JV Agreement (but currently seeking any of these), please provide details of current status and indicate why/how Prospective VITAL will meet eligibility requirements by Phase II Submission deadline (Assume deadline of May 7, 2024). Note the the Contracting Officer does not intend to intervene in any of these processes and the responsibility falls solely on the entity seeking any of these.

Offeror (Prospective VITAL) Name:

VITAL Eligibility (2,500 character limit)