16 SIR 16R00176_Atch 7_Bus Dec - 27Aug16.pdf
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- Solicitation number
- DTFAEN-16-R-00176
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OMB No. 2120-0595 DTFAEN-16-R-00176
Attachment 7
BUSINESS DECLARATION
Replacement of the roof at the Miami ARTCC (ZMA) and Wing stair roof, Miami, Florida
Prepared by:
Michael J. Hollis Contracting Officer, AAQ-510ATL
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 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 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? a. Yes b. No
12. Is the firm a service disabled veteran owned small business? a. Yes b. No
13. Is the firm a socially and economically disadvantaged 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.
14. a.
Signatur
b. Date:
c. Typed Name
d. Title:
OMB Control No. 2120-0595 FAA Template No. 61 (rev. 10/08)
| 16 RFO15-R-00164, MGM_Atch 5 Bus Dec - 25Aug15 |
| Business Declaration Form |
| (b) No. of Employees |
| (a) Years the firm has been in business |
| b. Partnership |
| a. Sole Ownership |
| Type of Ownership: |
| c. Other (Explain) |
| b.1. Gross Receipts |
| a.1. Year Ending: |
| Gross receipts of the firm for the last three years: |
| b.3. Gross Receipts |
| a.3. Year Ending: |
| b.2. Gross Receipts |
| a.2. Year Ending: |
| 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. |
| b. Date: |
| 14. a. Signature |
| d. Title: |
| c. Typed Name |
File details come from the government source that posted it. Updated .