Attachment II - Business Declaration.doc

DOC document 68 KB Posted

Attached to
Pre-Qualification: FAA WJHTC Building 316 Chillers Replacement Project Federal contract opportunity
Solicitation number
DTFACT-17-R-00012
Issued by
Department of Transportation Federal Aviation Administration Technical Center

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Attachment II - Business Declaration (doc)

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Other files for this federal contract opportunity

Other files attached to Pre-Qualification: FAA WJHTC Building 316 Chillers Replacement Project, newest first.
File Type Posted
Attachment III -B316-Chiller-Replacement-Project-Pre-qualification-Worksheet.docx DOCX document
B316-F2014074-FULL-SET-11-28-2016-E.pdf PDF
Specification - B316 Chiller Replacement.pdf PDF
Attachment I -B316-Chiller-Replacement-Project Draft SOW.doc DOC document

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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 .