ATT C- BUSINESS INFORMATION QUESTIONNAIRE.pdf

032417 Page 1 of 2

BUSINESS INFORMATION QUESTIONNAIRE (BIQ) FORM

NAME OF BUSINESS __________________________________________________________________

PRINCIPAL OFFICE ADDRESS __________________________________________________________

LOCAL OFFICE ADDRESS (SERVICING THE AIRPORT AUTHORITY): __________________________

TELEPHONE NUMBER ___________________ FAX NUMBER________________________________

EMAIL ______________________________ BUSINESS WEBSITE _____________________________

TAX ID NUMBER (TIN): ___________________________

FORM OF OWNERSHIP (Check One)

Corporation ( ) LLC ( ) Joint Venture ( )

State of Incorporation/Registration

Date of Incorporation/Registration

Partnership ( ) If Partnership, select one of the following: Limited ( ) or General ( )

Individual ( )

( ) Business is in Good Standing with the State of Michigan.

( ) Business is in Good Standing with the state in which this business is domiciled.

( ) This business is not required to obtain a Certificate of Good Standing or otherwise register with the State of Michigan (and its state of domicile, if different). Explain why_________________________

SMALL BUSINESS ENTERPRISE (SBE)

Is firm certified by the Airport Authority as a SBE? Yes ( ) No ( )

If yes, SBE Certification No. ____________

LIST OF PARTNERS, PRINCIPALS, CORPORATE OFFICERS OR OWNERS

Name Title

LIST OF CORPORATE DIRECTORS

Principal Business Affiliation Name Other Than Bidder Directorship

032417 Page 2 of 2

BUSINESS INFORMATION QUESTIONNAIRE (BIQ) FORM (continued)

ADDITIONAL INFORMATION REQUIRED BY THE AIRPORT AUTHORITY

LIST OF PRINCIPAL STOCKHOLDERS (i.e., those holding 5% or more of the outstanding stock)

Name Address

FINANCIAL DISCLOSURE/CONFLICTS OF INTEREST: Identify any contract(s), including any contract involving an employment or consulting relationship, which the firm, or its partners, principals, corporate officers or owners currently has with the Wayne County Airport Authority, or with any of its board members or officers.

Name of Business

Signature Date

Title

I hereby certify that the foregoing business information is true, correct and complete, that this business neither (a) engages in investment activities in the energy sector of Iran, including the provision of oil or liquefied natural gas tankers or products used to construct or maintain pipelines used to transport oil or liquefied natural gas for the energy sector of Iran, nor (b) extends credit to another person or entity, if that person or entity will use the credit to engage in investment activities in the energy sector of Iran:

FORCED LABOR PROVISION. The undersigned certifies that it does not use forced labor or engage in human trafficking/modern slavery in any of its operations or supply chains. This includes, but is not limited to, the use of forced or compulsory labor, bonded or indentured labor, and involuntary servitude. The undersigned also certifies that it is in compliance with all applicable laws and regulations related to forced labor and human trafficking/ modern slavery, including but not limited to The Uyghur Forced Labor Prevention Act (Public Law 117-78), and the

Victims of Trafficking and Violence Protection Act (Public Law 106-386) and agrees to promptly notify the Airport

Authority of any violations of this provision that are discovered during the performance of the contract. Failure to comply with this provision shall result in termination of the business relationship.