busdec8.doc
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- Solicitation number
- DTFACT-09-R-00045
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Business Declaration Form
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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 |
| 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: |
| FORMCHECKBOX |
a. Sole Ownership
FORMCHECKBOX
b. Partnership
FORMCHECKBOX
c. Other (Explain)
| 10. |
| 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 |
| 11. |
| Is the firm a small business? |
FORMCHECKBOX
a. Yes
FORMCHECKBOX
b. No
| 12. |
| Is the firm a service disabled veteran owned small business? FORMCHECKBOX |
a. Yes
FORMCHECKBOX
b. No
| 13. |
| Is the firm a socially and economically disadvantaged 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.
| 14. a. Signature |
| b. Date: |
| c. Typed Name |
| d. Title: |
OMB Control No. 2120-0595 FAA Template No. 61 (rev. 10/08)
File details come from the government source that posted it. Updated .