Attachment B - Business Declaration.doc
DOC document 74 KB Posted
- Attached to
- Market Survey - Voluntary Safety Reporting Program (VSRP) Support Federal contract opportunity
- Solicitation number
- VSRP0001
About this file
This market survey announcement requests capability statements and business declarations from vendors to support the Federal Aviation Administration's Voluntary Safety Reporting Programs. Vendors are asked to describe their ability to provide technical expertise to review safety events, develop presentation and reports, maintain reporting tools and databases, and conduct data analysis. They should also address experience with similar safety programs and modernizing reporting methods. The capability statement is limited to 10 pages. The business declaration form in Attachment B requests ownership and demographic information. Responses are due by July 6, 2021 and will be used for planning purposes only. No formal solicitation or contract award will result from this market survey.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attachment A - VSRP DRAFT Statement of Work.docx | DOCX document |
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Text version
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 |
| Controlling Interest in Company (“X” all appropriate boxes) |
FORMCHECKBOX
a. Black American
FORMCHECKBOX
b. Hispanic American
FORMCHECKBOX
c. Native American
FORMCHECKBOX
d. Asian American
FORMCHECKBOX
e. Other Minority (Specify)
| FORMCHECKBOX |
f. Other (Specify)
FORMCHECKBOX
g. Female
FORMCHECKBOX
h. Male
FORMCHECKBOX
i. 8(a) Certified (Certification letter attached) FORMCHECKBOX
j. Service Disabled Veteran Small Business
| 6 |
| 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? |
FORMCHECKBOX
a. Yes
FORMCHECKBOX
b. No (If “NO,” provide the name and telephone number of the person who has this authority.)
| 7 |
| Specify North American Industry Classification (NAIC) code |
| 8 |
| Nature of Business (Specify all services/products |
| 9 |
| (a) Years the firm has been in business |
| (b) No. of Employees |
| 10 |
| Type of Ownership: |
| FORMCHECKBOX |
a. Sole Ownership
FORMCHECKBOX
b. Partnership
FORMCHECKBOX
c. Other (Explain)
| 11. |
| Gross receipts of the firm for the last three years: |
| a.1. Year Ending: |
| b.1. Gross Receipts |
| a.2. Year Ending: |
| b.2. Gross Receipts |
| a.3. Year Ending: |
| b.3. Gross Receipts |
| 12. |
| Is the firm a small business? |
FORMCHECKBOX
a. Yes
FORMCHECKBOX
b. No
| 13. |
| Is the firm a service disabled veteran owned small business? FORMCHECKBOX |
a. Yes
FORMCHECKBOX
b. No
| 14. |
| Is the firm a socially and economically disadvantaged small business? FORMCHECKBOX |
a. Yes
FORMCHECKBOX
b. No
| 15 |
| Is the firm a woman-owned small business? FORMCHECKBOX |
a. Yes
FORMCHECKBOX
b. No
| I DECLARE THAT THE FOREGOING STATEMENTS CONCERNING |
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.
| 16 a. Signature |
| b. Date: |
| c. Typed Name |
| 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.
Business Declaration (10/2013)
File details come from the government source that posted it. Updated .