Business Declaration_plumbing and HVAC_238220.pdf

BUSINESS DECLARATION

Name of Firm:

2 Address of Firm:

3 a. Telephone 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)

Tax Identification No.:

DUNS No.:

b. Fax Number of Firm:

D a. Black American O b. Hispanic American D c. Native American D d. Asian American

D e. Other Minority (Specify) D f. Other (Specify)

D g. Female D h. Male D i. 8(a) Certified (Certification letter attached) D 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?

la. Yes lb.No (If "NO,• provide the name and telephone number of the person who has this authority.)

7 Nature of Business (Specify all services/products (NAICJJ

8 (a) Years the firm has been in business

238220; Plumbing, HVAC Contractors;

$15.0MIL (bl No. of Employees

9 Type of Ownership: D a. Sole Ownership Db. Partnership

D c. Other (Explain)

10. Gross receipts of the firm for the last three years:

a.2. Year b.2. Gross Ending: ____ _ Receipts ______ _

11. Is the firm a small business? r a. Yes lb. No a.1. Year Ending:

a.3. Year Ending:

12. Is the firm a service disabled veteran owned small business' r a. Yes r b. No

13. Is the firm a socially and economically disadvantaged small business? r a. Yes r b. No

I DECLARE THAT THE FOREGOING STATEMENTS CONCERNING

b.1. Gross Receipts b.3. Gross Receipts

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 uses 1001.

14. a.

Signature -----------------

c. Typed Name

OMB Control No. 2120-0595 b.Date:

d. Title:

FAA Template No. 61 {rev. 10/08)