Attachment 3 - Business Declaration Form.docx

BUSINESS DECLARATION

1. Name of Firm: Tax Identification No.:

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

5. Specify North American Industry Classification (NAIC) code

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

7. a. Years the firm has been in business b. No. of Employees

8.

9.

Is the firm a small business?

Is the firm a service-disabled veteran owned small business?

a. Yes b. No

a. Yes b. No

10. Is the firm a small, disadvantaged business? a. Yes b. No

11.

Is the firm a woman-owned small business?

a. Yes b. No

12. a. Signature

c. Typed Name b.

Date:

d. Title:

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.

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