Exhibit E - RegistrationCertForm_Updated.doc

Contra Costa County Business Opportunities

REGISTRATION AND CERTIFICATION FORM

If you are interested in receiving information regarding upcoming business opportunities with Contra Costa County, please fill out the form below. Your information will be included in the County’s SBE and Outreach Databases and used by County departments to: 1) notify you regarding upcoming contracting and bidding opportunities and/or 2) certify your firm as a Small Business Enterprise (if applicable).

SECTION 1 – CONTACT INFORMATION

Name of Firm (Print)

Street Address (City, State) (Zip Code)

Mailing Address (City, State) (Zip Code)

Contact Numbers (Check preferred)

( Business Phone Number

( Cell Phone Number

Fax Number

SECTION 2 – WORK CONDUCTED BY FIRM

(Generally describe what your firm does)

Vendor/Supplier

Consultant/

Service Provider

Construction

Other

(If none of the above categories apply)

SECTION 3 –DESCRIPTION OF BUSINESS

Description of Business Type (Check all that apply):

Small Business Enterprise (SBE) – independently owned and operated; cannot be dominant in its field of operation; must have its principal office located in California; must have its owners (or officers in the case of a corporation) domiciled in California;

AND together with affiliates, be either: a business with 100 or fewer employees, an an average annual gross receipts of $14 million or less over the previous three tax years, or a manufacturer with 100 or fewer employees.

Minority Business Enterprise (MBE) - at least 51% owned and managed on a daily basis by one or more minorities who are citizens or lawful permanent residents of the United States and member(s) of a recognized ethnic or racial group AND its home office is located in the United States.

Women Business Enterprise (WBE) - at least 51% owned and managed on a daily business by one or more women who are citizens or lawful permanent residents of the United States AND its home office is located in the United States.

Disadvantaged Business Enterprise (DBE) - at least 51% owned and managed on a daily business by socially- and economically-disadvantaged individuals (pursuant to Section 3 of the Small Business Act). DBE certifications are used only for state- or federally-funded projects that have DBE goals or requirements.

Disabled Veteran Business Enterprise (DVBE) - at least 51% owned and managed on a daily basis by one or more disabled veterans of the military, naval, or air service of the United States with a service-connected disability of at least 10 percent, and who is also a resident of California; AND a sole proprietorship corporation or partnership with its home office located in the United States that is not a subsidiary of a foreign firm.

Local Business Enterprise (LBE) - principal place of business is located within the boundaries of Contra Costa County.

None of the above

Contra Costa County Business Opportunities

REGISTRATION AND CERTIFICATION FORM

SECTION 4 – CERTIFICATION BY OTHER AGENCIES

State-Certified SBE:

Yes No

State Certification #:

If “Yes,” please attach documentation.

Are you certified with any other agencies as a: Minority Business Enterprise (MBE), Woman Business Enterprise (WBE), Disabled Veteran Business Enterprise (DVBE), or Disadvantaged Business Enterprise (DBE): Yes

No

If “Yes,” please list agency AND attach documentation:

SECTION 5 – ACKNOWLEDGEMENT OF COUNTY’S USE OF BUSINESS INFORMATION

The undersigned acknowledges and agrees that the information provided in this form may be included in the SBE and Outreach databases maintained by or for the County, including the e-Outreach system described below.

SECTION 6 – UPDATING CONTACT INFORMATION AND BUSINESS STATUS

Firms interested in business opportunities with Contra Costa County are strongly encouraged to register on the e-Outreach system maintained for the County at: https://www.bidnetdirect.com. Although the information contained in this form will be added to that system, firms are encouraged to register and update their information on the above website to 1) provide more detailed information regarding their area of work, and 2) ensure that they continually receive notices about business opportunities with Contra Costa County.

Your firm’s registration with Contra Costa County will be valid for three years from the date this form is entered into the County’s database. After that three-year period, your firm will be required to either confirm or update the information contained herein.

SECTION 7 – CERTIFICATION OF BUSINESS INFORMATION

The undersigned certifies and swears under penalty of perjury that all information contained in this form is true and correct. Any material misrepresentation will be grounds for terminating any purchase orders or contracts which may be or have been awarded as well as deleting the business from the online SBE and Outreach databases maintained by the County and the County’s database contractor.

By ________________________________________________

Print Name

Title

Signature

Date

Return this Self-Certification Form to:

Contra Costa County

Public Works, Purchasing Division 40 Muir Road, 2nd Floor

Martinez, CA 94553

Fax: 925-372-3643

For clarification or assistance with

Contra Costa County this form, please contact:

Purchasing Division Phone: 925-655-3100

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Revised 1/31/2025 RegistrationCertForm 1312025