Sources_Sought_Form_OHWS.pdf

Socio-economic status for the listed NAICS code - please check all that apply:

( ) Large business ( ) Small business

( ) Small disadvantaged business ( ) 8(a) program participant

( ) HUB Zone business ( ) Woman-Owned business

( ) Service-Disabled Veteran-Owned Small Business (SDVOSB)

By responding to the Sources Sought Notice, I confirm that my firm is registered in the System for Award Management (SAM) https://www.sam.gov/ with the socio-economic status identified above and the NAICS code specified in the sources sought notice; or that my firm qualifies and registration under the applicable NAICS code is in process.

Certification:

I understand that incomplete answers in sections or my failure to provide required documentation or failure to sign this certification may remove my firm from the Government’s determination of whether to solicit the referenced project on a set-aside basis in accordance with Part 19 of the Federal Acquisition Regulation.

Name: __________________________________

Title: __________________________________

Signature: __________________________________

NGB February 2018 A-25

NAICS Code: 621340

Interested firms please respond with this information form and the following requested information. Please complete all sections of the document.

1.Company Information.

Company Name:

Company Address as registered in System for Award Management (SAM):

CAGE Code:

DUNS Number: