Attachment L-3 - Business Declaration Form.pdf

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11.0.0.20130303.1.892433 OMB Control No. 2120-0595 Business Declaration FAA Template No. 61 (rev. 10/08) Specify North American Industry Classification (NAIC) code

b. Date:

d. Title:

16. a. Signature

c. Typed Name Privacy Act Statement: Privacy Act Statement (5 U.S.C. § 552a, as amended). AUTHORITY: FAA Acquisition Management System (49 USC 40110) authorizes us to collect this information. PURPOSE(S): We will use the information provided to determine your business ownership and eligibility for contracts set-aside for certain types of businesses. ROUTINE USE(S): We may share your information among our offices involved in small business development and contracting, and may also use the information for statistical reporting. DISCLOSURE: Providing the requested information is voluntary; however failure to furnish the information may result in ineligibility to participate in set-aside contracting.

ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF. I AM AWARE THAT I AM SUBJECT TO CRIMINAL PROSECUTION UNDER THE PROVISIONS OF 18 USCS 1001.

I DECLARE THAT THE FOREGOING STATEMENTS CONCERNING

Tax Identification No.:

Name of Firm:

1.

2.

Address of Firm:

DUNS No.:

3.

a. Telephone Number of Firm:

b. Fax Number of Firm:

4.

a. Name of Person Making Declaration

b. Telephone Number of Person Making Declaration

c. Position Held in the Company Controlling Interest in Company (“X” all appropriate boxes)

e. Other Minority (Specify)

f. Other (Specify)

a. Black American

b. Hispanic American

c. Native American

d. Asian American

g. Female

h. Male

i. 8(a) Certified (Certification letter attached)

j. Service Disabled Veteran Small Business Is the person identified in Number 4 above, responsible for day-to-day management and policy decision making, including but not limited to financial and management decisions?

(If “NO,” provide the name and telephone number of the person who has this authority.)

a. Yes

b. No Nature of Business (Specify all services/products (NAIC))

b. Partnership

a. Sole Ownership

c. Other (Explain) a.1. Year Ending:

b.1. Gross Receipts $ a.3. Year Ending:

b.3. Gross Receipts $ b.2. Gross Receipts $ a.2. Year Ending:

a. Yes

b. No Is the firm a small business?

a. Yes

b. No Is the firm a service disabled veteran owned small business?

Is the firm a small disadvantaged business?

a. Yes

b. No

a. Yes

b. No Is the firm a woman-owned small business?

10.

11.

12.

13.

14.

15.

9.

8.

7.

6.

5.

b. No. of Employees

a. Years the firm has been in business Type of Ownership:

Gross receipts of the firm for the last three years:

BUSINESS DECLARATION