Business Declaration Form.pdf

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11.0.0.20130303.1.892433 OMB Control No. 2120-0595 FAA Template No. 61 (rev. 10/08)

BUSINESS DECLARATION

Name of Firm:

Tax Identification No.:

Address of Firm:

DUNS No.:

a. Telephone Number of Firm:

b. Fax Number of Firm:

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)

a. Black American

b. Hispanic American c.

Native American

d. Asian American e Other Minority (Specify) f.

Other (Specify) 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?

a.

Yes

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

Nature of Business (Specify all services/products (NAIC))

(a) Years the firm has been in business

(b) No. of Employees Type of Ownership:

a.

Sole Ownership

b. Partnership

c. Other (Explain) 10.

Gross receipts of the firm for the last three years:

a.1. Year Ending:

b.1. Gross Receipts a.2. Year Ending:

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

b.3. Gross Receipts 11.

Is the firm a small business?

a. Yes b.

No 12.

Is the firm a service disabled veteran owned small business?

a. Yes b.

No 13.

Is the firm a socially and economically disadvantaged small business?

a. Yes b.

No

I DECLARE THAT THE FOREGOING

STATEMENTS CONCERNING

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.

14. a.

Signature

b. Date:

c. Typed Name

d. Title: