Attachment 2 - Business Size - Preliminary Past Performance Review Form.pdf

BUSINESS SIZE AND PRELIMINARY PAST PERFORMANCE VALIDATION FORM

NATIONAL NAVCOM/NAVAIDS FALL PROTECTION SYSTEM UPGRADES FOR THE

AIR TRAFFIC ORGANIZATION (ATO) - QUALIFIED VENDOR LIST

DUE DATE: SEPTEMBER 21, 2023 @3:00PM EST

EMAIL: SONIA.O.HOLGUIN@FAA.GOV

AIR TRAFFIC ORGANIZATION (ATO)- QUALIFIED VENDOR LIST

COMPANY PROFILE:

a. Company name and DUNS number as registered on https://sam.gov/SAM/

Company Name:

DUNS No.:

Note: Ensure your company profile is active and up to date on https://sam.gov/SAM/

b. What is the company business size classification under NAICS Code: 541330 Engineering Services?

☐ Large ☐ Small

c. Does the business size classification under NAICS Code: 541330 Engineering Services in the Firm’s SAM registration reflects small business

☐No ☐Yes

☐NA

Is the firm a Small Disadvantaged Business (SDB) as prescribed in the Code of Federal Regulations (CFR) Title 13 Part 124.103 and is certified and listed on the public registry?

☐No ☐Yes

☐NA

d. Is the firm a Veteran-Owned Small Businesses (VOSB) or Service-Disabled Veteran-Owned Small Businesses (SDVOSB) and has been verify by the Veterans Administration Center for Verification and Evaluation?

☐No

e. Is the firm qualified as a socially and economically disadvantaged small business and as is certify under the 8(a) Small Business Program?

☐No https://sam.gov/SAM/ https://sam.gov/SAM/

If yes please make attach the official designation letter.

f. Is the firm a certify Women-Owned Small Businesses (WOSBs) or Economically

Disadvantaged WOSBs (EDWOSBs).

☐No

g. Is the firm a HUBZone small business as prescribed in Title 13 Part 126 Subpart B of the Code of Federal Regulations and certified by the Small Business Administration (SBA)?

☐No

PRELIMINARY PAST PERFORMANCE REVIEW:

a. Has your Company had any Contract Terminations since September 2018?

☐No ☐Yes If yes please provide more explanation/documentation attached with your validation package.

b. Has your Company been given an unsatisfactory performance rating or deemed a poor performer (by letter or formal proceeding) since September 2018?

☐No ☐Yes

c. Has your company been suspended, debarred, or disqualified from Government contracting since September 2018?

☐No ☐Yes

d. Has your company been investigated by the Department of Labor since September 2018?

☐No

If yes please provide more explanation/documentation attached with your validation form.

FIRM’s POINT OF CONTACT:

Complete the table below with the most up to date POC’s Name Phone Number Email Address

1.

2.

Note: Your Company is responsible to notify FAA of any POC changes

SIGNATURE/CERTIFICATION:

I hereby certify that all information provided in the Validation Form is true and correct..

Name:

Title:

Signature:

Date: