FORM 3 - BUSINESS DATA SHEET.pdf

FORM 3 - BUSINESS DATA SHEET PAGE 1 OF 2

TO BE COMPLETED BY PRIME AND ALL SUBCONTRACTORS LISTED ON FORM 1

Completion of this Form and Form 1 (or Form 4) fulfills the requirements of the California Subletting & Subcontracting Fair Practices Act.

PART A: BUSINESS DATA

1. Business Name: __________________________________________________________________________________________

2. IFB/RFP/RFIQ Number: ____________________________________________________________________________________

3. Project Name: ____________________________________________________________________________________________

4. Is your business currently SBE certified by Metro?

(If marked “SBE”, a copy of the certification letter for this business must be attached to this Form) SBE Non-SBE

5. Is your business Metro certified as a Local SBE (LSBE) firm? YES NO (If yes, LSBE certification date): ____________________________________________________

6. Is your business currently a DVBE certified by the CA Department of General Services?

(If marked “DVBE”, a copy of the certification letter for this business must be attached to this Form) DVBE Non-DVBE

7. Is your business currently participating in a Joint Venture?

(If answered YES, a copy of the Joint Venture Agreement must be attached to this Form) YES NO

8. Name of Joint Venture and Partners. Is this business currently a certified SBE/DVBE?

a. Business Name: ___________________________________________________ SBE DVBE Non-Cert.

Name of Certifying Agency: _____________________________________________

b. Business Name: ___________________________________________________ SBE DVBE Non-Cert.

Name of Certifying Agency: _____________________________________________

c. Business Name: ___________________________________________________ SBE DVBE Non-Cert.

Name of Certifying Agency: _____________________________________________

9. Primary Business Address: __________________________________________________________________________________ (Street) (City) (State) (Zip)

10. Mailing Address: __________________________________________________________________________________________ (Street) (City) (State) (Zip)

11. County Business is located in: _______________________________________________________________________________

12. Name of Contact Person: ____________________________________________, ______________________________________ (Name) (Title)

13. Phone:(_______) _________ - ______________ 11.Email Address: ___________________________________

12. Fax: (_______) _________ - ______________ 13. Age of Business: ______ Years, and _______ Months

14. If your business requires a license, complete below. 15. Business Annual Gross Receipts:

a. License Type: __________________________ a. Less than $500,000

b. $500,000 to $1,000,000

b. License #: __________________________ c. $1,000,000 to $2,000,000

d. $2,000,000 to $5,000,000

c. Expiration: __________________________ e. $5,000,000 to $25,000,000

f. Over $25,000,000

16. If the Work/Services require DIR Registration, per California Labor Code §1725.5, complete below:

a. DIR Registration No: _________________________________

b. DIR Registration Date: ________________________________

FORM 3 - BUSINESS DATA SHEET (Continued) Page 2 of 2

PART B: WORK DESCRIPTIONS

17. Identify the scope of work that will be performed by this SBE/DVBE business. For SBE Firms, provide ONLY applicable Northern America Industry Classification System (NAICS)1 code(s). For DVBE Firms, provide ONLY applicable United Nations Standard Products and Services (UNSPSC)2 code(s).

Description of Work, Service, or Materials Supplied SBE NAICS (6 digits) or DVBE UNSPSC (8 digits) Code(s)

18. Will your business provide trucking company services on this project? Yes No

If marked YES, please complete items a. to c. below. If answered NO, answer “Not Applicable.”

a. How many trucks does your company own? ____________________

b. How many trucks does your company lease? ____________________

c. How many trucks are registered to your company? ____________________

PART C: SIGNATURE

The undersigned Director, Officer, General Partner, or similarly situated Principal of the business declares he/she is informed and believe, and thereon allege, that to the best of their knowledge, information and belief, the information set forth on this page of this document and any attachments, is current, complete and accurate.

Business Name:

Authorized Signature:

Printed Name:

(Signature of Director, Officer, General Partner or similarly situated Principal of the Business)

Title:

Date:

1Northern America Industry Classification System (NAICS) are provided by Metro Certification 2United Nations Standard Products and Services (UNSPSC) are provided by the Department of General Services To receive credit, your firm must be certified in applicable codes