Attachment 3 - Business Declaration Form.pdf
PDF 110 KB Posted
- Solicitation number
- AAQ-240-ALFS
About this file
This document is a business declaration form used by the Federal Aviation Administration to collect ownership and eligibility information from firms interested in set-aside contracts. The form collects details about the business such as name, address, DUNS number, ownership type, gross receipts, number of employees, years in business, and certifications. It asks the respondent to identify their role and authority within the company. The related federal contract opportunity is a pre-solicitation notice from the Department of Transportation and Federal Aviation Administration Enroute Terminal Contracts for a market survey of the Alaska Flight Service Automated System. No other salient details are provided about products or services required, response dates, or award information.
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Text version
OMB Control No. 2120-0595
1Business Declaration
FAA Template No. 61 (rev. 10/08)
Specify North American Industry Classification (NAIC) code
b. Date:
d. Title:
16. a. Signature
c. Typed Name
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.
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.
I DECLARE THAT THE FOREGOING STATEMENTS CONCERNING
Tax Identification No.: Name of Firm: 1.
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
Controlling Interest in Company (“X” all appropriate boxes)
e. Other Minority (Specify) f. Other (Specify)
a. Black American b. Hispanic American c. Native American d. Asian American
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?
(If “NO,” provide the name and telephone number of the person who has this authority.)a. Yes b. No
Nature of Business (Specify all services/products (NAIC))
b. Partnership a. Sole Ownership
c. Other (Explain) a.1. Year Ending: b.1. Gross Receipts $ a.3. Year Ending: b.3. Gross Receipts $ b.2. Gross Receipts $a.2. Year Ending:
a. Yes b. NoIs the firm a small business?
a. Yes b. No Is the firm a service disabled veteran owned small business?
Is the firm a small disadvantaged business? a. Yes b. No
a. Yes b. No Is the firm a woman-owned small business?
10.
11.
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15.
9.
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b. No. of Employees a. Years the firm has been in business
Type of Ownership:
Gross receipts of the firm for the last three years:
BUSINESS DECLARATION
File details come from the government source that posted it. Updated .