FORM 3 - SBE BUSINESS DATA SHEET.pdf

LACMTA

SBE INSTR TO BIDDERS/PROPOSER SET-ASIDE (NON-

FED)

PRO FORM 069C

REVISION DATE: 02.06.19

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. Is your business currently SBE certified by Metro (LACMTA)?

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

3. 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

4. Name of Joint Venture and Partners. Is this business currently a certified SBE?

a. Business Name: ______________________________________________________ SBE Non-Cert.

Name of Certifying Agency: ________________________________________________

b. Business Name: ______________________________________________________ SBE Non-Cert.

c. Business Name: ______________________________________________________ SBE Non-Cert.

5. Primary Business Address: _______________________________________________________________________________ (Street) (City) (State) (Zip)

6. Mailing Address: _______________________________________________________________________________________ (Street) (City) (State) (Zip)

7. County Business is located in: ____________________________________________________________________________

8. Name of Contact Person: ____________________________________________, ___________________________________ (Name) (Title)

10. 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. B2GNow Vendor Record Number: __________________________

LACMTA

SBE INSTR TO BIDDERS/PROPOSER SET-ASIDE (NON-

FED)

PRO FORM 069C

REVISION DATE: 02.06.19

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

Part B: Work Descriptions

17. Identify the scope of work and corresponding North American Industry Classification System (NAICS)

Code(s) that will be performed by this business. If business is an SBE, list only the NAICS Codes, in which the firm is certified to perform work on this contract ONLY.1

DESCRIPTION OF WORK, SERVICE, OR MATERIALS

SUPPLIED TO BE PERFORMED ON THIS CONTRACT

CORRESPONDING NAICS CODE(S) (6 DIGITS)

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:

1To receive credit, your firm must be certified in applicable NAICS Codes