Attachment 19 - Business Declaration Form.pdf

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)

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

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

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

a. Yes b. No (If “NO,” provide the name and telephone number of the person who has this authority.)

7 Specify North American Industry Classification (NAIC)

8 Nature of Business (Specify all services/product)

9 (a) Years the firm has been in business (b) No. of Employees

10 Type of Ownership: a. Sole Ownership b. Partnership

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? a. Yes b. No

13. Is the firm a service disabled veteran owned small business? a. Yes b. No

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

15 Is the firm a woman-owned small business? a. Yes 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)

Kathleen D Islas Typewritten Text

Kathleen D Islas Typewritten Text

Kathleen D Islas Typewritten Text

Kathleen D Islas Typewritten Text Attachment 19

DTFAAC-15-R-02838