Vendor Self Certification Form.pdf

VENDOR SIZE SELF-CERTIFICATION

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Name: Business Name:

Check appropriate box: □ Individual/Sole Proprietor □ Corporation □ Partnership □ Other

Address (number, street and apt. or suite no.)

City, State, and ZIP code

If applicable, DUNS Number:

NAICS Code - 6 digits Small Business (Y/N)?

Primary

Commodity: (check all that apply)

□ Advertising/Marketing Services □ Hospitality/Events/Food & Beverage □ Scientific/Research/Laboratory

□ Agriculture □ Human Resources & Personnel Services □ Shipping

□ Construction & Related Services □ IT □ Transportation/Automotive

□ Facilities/MRO □ Manufacturing □ Travel

□ Financial Services □ Medical

□ Furniture & Furnishings □ Printing/Publications/Promo

Certification:

NOTICE: Under 15 U.S.C. § 645(d), any person who misrepresents its size or socioeconomic status shall be (1) punished by a fine, imprisonment, or both; (2) subject to administrative remedies; and (3) ineligible for participation in programs conducted under the authority of the Small Business Act.

X Signature Date

Name (printed or typed) Title

Telephone E-Mail Address

Business Size: (check one) □Small □Other Than Small Business (large, government, non-profit, foreign, individuals

□ SBA 8(a) Business

□ Veteran-Owned Small Business Service

□ Service Disabled Veteran-Owned Small Business

□ Women-Owned Small Business

NAICS Description

□ Alaskan Native Corporation or Indian Tribe

□ Historically Black College or University

□ HUBZone Small Business

□ Small Disadvantaged Business

□ Minority Business Enterprise

6010 Campus Delivery Fort Collins, CO 80523-6010 smallbusiness@colostate.edu not identifying as a small business) may skip to Certification at the bottom

Small Business Classification (select all applicable):

□ Economically Disadvantaged Women-Owned Business

□ Women Business Enterprise

□ LGBTQIA+ Business Enterprise aarment Highlight

Small Business Classification Definitions:

Small Business (SB) - A Small Business that is independently owned and operated by an American citizen and which is not dominant in its field of operation. The size definition will vary from industry to industry and is based on the North American Industry Classification System (NAICS) codes either by number of employees or gross annual sales. The website for Size Standard and NAICS lookup is: https://eweb1.sba.gov/naics/dsp_naicssearch2.cfm

Alaskan Native Corporation or Indian Tribe (ANC) - An ANC means any Regional Corporation, Village Corporation, Urban Corporation or Group Corporation organized under the laws of the State of Alaska in accordance with the Alaska Native Claims Act, as amended by 43 U.S.C 1601. In addition and as defined in federal regulations, a tribally owned business (concern) means any business (concern) that is at least 51% owned by an Indian tribe. An Indian tribe is any Indian tribe, band, nation or other organized group or community of Indians, including any ANC, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians or is recognized as such by the State in which the tribe, band, nation or community resides.

Historically Underutilized Business Zone Small Business (HUBZone) - An SB with its principal office located within a HUBZone, which includes lands on federally recognized Indian reservations; owned and controlled by one or more U.S. citizens and at least 35% of its employees must reside in a HUBZone. The website is: https://www.sba.gov/federal-contracting/contracting-assistance-programs/hubzone-program. Must be certified as HUBZone by the Small Business Administration.

Small Disadvantaged Business (SDB) - An SB that is at least 51% owned and operated, or in the case of any publicly owned business, at least 51% of the stock of which is owned and operated by socially and economically disadvantaged individual or individuals. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans are presumed to qualify. Other individuals can qualify if they show a "preponderance of the evidence" that they are disadvantaged. All individuals must have a net worth of less than $750,000, excluding the equity of the business and primary residence. The website is: http://sbagov.org/government_opportunities/federal_contracting_guide/small_disadvantaged_business.htm.

Must be certified as SDB by the Small Business Administration.

SBA 8(a) Business -The 8(a) Business Development Program is a business assistance program for small disadvantaged businesses.

The 8(a) Program offers a broad scope of assistance to firms that are owned and controlled at least 51% by socially and economically disadvantaged individuals.

Veteran-owned Small Business (VOSB) - An SB that is at least 51% owned and operated by one or more veteran(s), or, in the case of any publicly owned business, at least 51% of the stock of which is owned by one or more veterans, who actively served in the U.S.

military, naval, or air service and were honorably discharged. The website is: https://www.sba.gov/offices/headquarters/ovbd/ resources/1558568

Service-Disabled Veteran-owned Small Business - Same criteria as VOSB except the veteran has a disability that is service-connected.

Women-owned (WOSB)/Economically Disadvantaged Women-Owned (EDWOSB) Small Business- A WOSB is at least 51% owned and operated by one or more women. A EDWOSB is 51 percent directly and unconditionally owned and controlled by one or more women who are citizens (born or naturalized) of the United States and who are economically disadvantaged.

NAICS Code: Provide your primary North American Industry Classification System (“NAICS”) codes, descriptions and size standard for the products or services that your company is providing. In addition, provide any other NAICS codes that you can be considered for doing business with Colorado State University. NAICS codes are needed for the Summary Subcontract Report breakout report that we are required to submit to the government annually pursuant to FAR 52.219-9(1)(2)(iii).

For legal definitions and assistance, contact your local Small Business Administration office. In Colorado, it is S B A, Colorado District Office, 721 19th Street, Suite 426, Denver, Colorado 80202, telephone 303-844-2607. Size standard information is available at https://www.sba.gov/size-standards/

INSTRUCTIONS

Please complete the top section of the certification form, providing as much information as possible, including your DUNS number. Dun & Bradstreet (D&B) provides a D-U-N-S Number, a unique nine-digit identification number, for each physical location of your business. D-U-N-S Number assignment is FREE for all businesses required to register with the US Federal government for contracts or grants.

Foreign businesses: Please complete the top section of the certification form, checking "other" for business type and listing foreign or international. Under Business Size select "Other Than Small Business", and complete Certification on the bottom of the page.

http://www.sba.gov/sdb/indexaboutsdb.html https://eweb1.sba.gov/naics/dsp_naicssearch2.cfm https://www.sba.gov/federal-contracting/contracting-assistance-programs/hubzone-program https://www.sba.gov/federal-contracting/contracting-assistance-programs/hubzone-program https://www.sba.gov/federal-contracting/contracting-assistance-programs/hubzone-program http://sbagov.org/government_opportunities/federal_contracting_guide/small_disadvantaged_business.htm https://www.sba.gov/offices/headquarters/ovbd/ https://www.sba.gov/size-standards/