RFP_Media_Agent_Exhibit_C_(OCon_Form_650).pdf

OCon 650, Revenue-Generating Contracts – Representations and Certifications

October 2010

Smithsonian Institution OCon 650

Revenue-Generating Contracts - Representations and Certifications Form

In accordance with its status as a public trust, the Smithsonian Institution desires to create and enter into revenue-generating opportunities with organizations from a diverse economic base. These organizations not only include small businesses and economically disadvantaged businesses, but also those businesses that are the cornerstone of their respective industries. The Smithsonian requests that you complete and return the form below. Collection of this information is not compulsory and is for informational purposes only.

THE PROSPECTIVE CONTRACTOR HEREIN REPRESENTS THE FOLLOWING [check all that apply]:

1. Concern operates as ( ) an Individual, ( ) a Partnership, ( ) a Non-Profit Organization, ( ) a Corporation – incorporated under the laws of the State of .

2. Concern IS ( ), IS NOT ( ), a SMALL BUSINESS. A small business is an independently owned and operated concern that is not dominant in its field and can further qualify under the criteria prescribed by the

Small Business Administration (SBA) in 48 CFR 19.001.

3. Concern IS ( ), IS NOT ( ), a SMALL DISADVANTAGED BUSINESS. A small disadvantaged business is a small business that is at least 51 percent owned by one or more socially and economically disadvantaged individuals; or in the case of any publicly owned business, at least 51 percent of the stock is unconditionally owned by one or more socially and economically disadvantaged individuals, and whose management and daily business operations are controlled by one or more of these individuals.

4. Concern IS ( ), IS NOT ( ), a WOMAN-OWNED SMALL BUSINESS. A Woman-Owned small business is a small business that is at least 51 percent owned, controlled, and operated by a woman or women. “Control” in this context means exercising the power to make policy decisions. “Operate” in this context means being actively involved in the day-to-day management of the business.

5. Concern IS ( ), IS NOT ( ), a HUB-ZONE SMALL BUSINESS. A Hub-Zone small business is a small business that appears on the List of Qualified HUBZone Small Business Concerns maintained by the SBA.

Historically Underutilized Business Zone (HUB Zone) means an area located within one or more qualified census tracts, qualified non-metropolitan counties, or lands within the external boundaries of an Indian reservation.

6. Concern IS ( ), IS NOT ( ) a VETERAN-OWNED SMALL BUSINESS. A Veteran-owned small business is a small business (1) Not less than 51 percent of which is owned by one or more veterans (as defined at

38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and (2) The management and daily business operations of which are controlled by one or more veterans.

7. Concern IS ( ), IS NOT ( ) a SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS. A

Service-disabled veteran-owned small business means a small business (i) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than

51 percent of the stock of which is owned by one or more service-disabled veterans; and (ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran. A “Service-disabled veteran” is a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16).

8. Concern elects NOT to complete the information requested above. ( )

Signature: Date:

Name & Title:

Organization:

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