Appendix SDVOB-3 - SDVOB 200 Application for Waiver of SDVOB Participation Goal3.pdf

SDVOB 200 (01/18) Page 1 of 2

Purchase & Contracts, SDVOB Administrator Harriman State Office Campus, Building 12, Room 465

Albany, NY 12240 Phone: (518) 474-2678 | Fax: (518) 457-0620

Labor.sm.SDVOBAdmin@labor.ny.gov

Application for Waiver of SDVOB Participation Goal

Section 1: Basic Information Contractor’s Name: Federal Identification No.:

Street Address: E-mail address:

City, State, Zip Code: Telephone No.: ( ) -

Solicitation/Contract No.: SDVOB Contract Goals

6%

Section 2: Type of Waiver Requested Total Partial If partial waiver, please enter the revised SDVOB percentage: %

Please explain the reason for the waiver request:

Text field will expand as you type.

Section 3: Supporting Documentation

Provide the following documentation as evidence of your good faith efforts to meet the SDVOB goals set forth in the contract and in support of your waiver application:

Attachment A. Copies of solicitation to certified SDVOB and any responses thereto.

Attachment B. Explanation of the specific reasons each SDVOB that responded to Bidders/Contractors’ solicitation was not selected.

Attachment C Dates of any pre-bid, pre-award or other meetings attended by Contractor, if any, scheduled by the Department of Labor with certified SDVOBs whom the Department of Labor determined were capable of fulfilling the SDVOB goals set in the contract.

Attachment D. Information describing the specific steps undertaken to reasonably structure the contract scope of work for the purposes of subcontracting with, or obtaining supplies from certified SDVOBs.

Attachment E. Other information deemed relevant to the request.

Section 4: Signature and Contact Information

By signing and submitting this form, the contractor certifies that a good faith effort has been made to promote SDVOB participation pursuant to the SDVOB requirements set forth under the solicitation or Contract. Failure to submit complete and accurate information may result in a finding of noncompliance, non-responsibility, and a suspension or termination of the contract.

Prepared by (signature): Date:

Name and title of preparer (print):

For Department of Labor Use Only

Solicitation/Contract No.:

Appendix SDVOB-3

SDVOB 200 (01/18) Page 2 of 2

Reviewed By: Date:

Decision:

Full SDVOB waiver Granted

Partial SDVOB waiver Granted; revised SDVOB goal: %

SDVOB waiver Denied

Approved By: Date:

Date Notice of Determination Sent:

Comments: