INFORMATION_PAGE.pdf

INFORMATION PAGE

49 CFR, Part 26 requires that all recipients of federal funds collect certain information from all bidders submitting responses to solicitations. Please fill out this form completely. Any offer that does not contain a completed copy of this form will be ruled as non-responsive and dropped from further consideration in the procurement process for this solicitation.

Company: ___________________________________________________________________

Address: ________________________________________________________________________

City: _______________________________________ State: ___________ Zip: ____________

Contact Name: __________________________________________________________________

Telephone: ________________________________ Fax: ________________________________

Email Address: __________________________________________________________________

General Classification of Firm by Number of Employees:

___ Less Than 10 ___ 11- 50 ___ 51 - 100 ___ 101 - 500

___ 501 - 1000 ___ 1001 - 5000 ___ More Than 5000

General Classification of Firm in Age of Existence:

___ 0 - 5 Years ___ 6 - 10 Years ___ 11 - 50 Years ___ Over 50 Years

General Classification of Firm by Annual Gross Income:

___ Less than $100,000 ___ $100,000 - $ 250,000 ___ $250,001 - $500,000

___ $500,001 - $1,000,000 ___ $1,000,001 - $5,000,000 ___ Over $5,000,000

General Classification of Firm by Type:

___ Firm is a certified DBE ___ Firm is a certified MBE

___ Firm is a certified WBE ___ Firm is not certified as any of the previous types

I certify this information is accurate to the best of my knowledge.

Signature: __________________________________________________ Date: _____________________