BUSINESS DECLARATION.docx
DOCX document 15 KB Posted
- Attached to
- Market Survey for Construction Projects at the Cleveland Air Route Traffic Control Center, Oberlin, OH
- Solicitation number
- 697DCK-24-R-MMKC1
About this file
This document is a Business Declaration form that provides information about a firm's ownership, business characteristics, and financial data. The key details are:
The form requests information on the firm's name, address, tax ID, UEI number, telephone number, and contact person. It asks about the firm's controlling interest (e.g. minority, woman-owned, etc.), day-to-day management, nature of business, years in business, number of employees, and gross receipts for the past 3 years. The firm is also asked to indicate if it qualifies as a small business, 8(a) certified business, service-disabled veteran-owned small business, HUBZone certified, woman-owned small business, or certified EDWOSB. The person completing the form must certify the accuracy of the information provided.
This Business Declaration form is related to a pre-solicitation market survey for construction projects at the FAA's Cleveland Air Route Traffic Control Center in Oberlin, Ohio. The FAA is seeking interested small, disadvantaged, 8(a), SDVOSB, WOSB/EDWOSB, or HUBZone firms to perform a range of construction work valued between $50,000 - $500,000. Interested firms must have an active SAM.gov registration and past experience with federal agency projects.
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Text version
BUSINESS DECLARATION
1. Name of Firm: Tax Identification No.:
2. Address of Firm: UEI No.:
3. Telephone Number of Firm:
4. a. Name of Person Making Declaration
b. Position Held in the Company
c. Telephone Number of Person Making Declaration
d. Email
5. Controlling Interest in Company (“X” all appropriate boxes)
a. Black American b. Hispanic American c. Native American
d. Asian American e. Other Minority (Specify) f. Other (Specify)
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?
a. Yes b. No (If “NO,” provide the name and telephone number of the person who has this authority.)
7. Nature of Business (Specify all services/products (NAIC))
8. a Years the firm has been in business b. No. of Employees
9. Type of Ownership: a. Sole Ownership b. Partnership
c. Other (Explain)
10. Gross receipts fo the firm for the last three years:
a.1. Year Ending: b.1. Gross Receipts $ a.3. Year Ending: b.3. Gross Receipts $ a.2. Year Ending: b.2. Gross Receipts $
11. Is the firm a Small Business? a. Yes b. No
12. Is the firm an 8a Certified Business a. Yes b. No
13. Is the firm a Service Disabled Veteran Owned Small Business? a. Yes b. No
14. Is the firm Hubzone Certified a. Yes b. No
15. Is the firm a Certified Woman-Owned Small Business? a. Yes b. No
16. Is the firm a Certified EDWOSB? a. Yes b. No
I declare that the foregoing statements 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.
Signature Date
Typed Name 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.
File details come from the government source that posted it. Updated .