Important!
As an active Entergy supplier and in order to enable the company to meet its federal government reporting requirements, you are required (if qualified) to self-certify your company’s ownership status.
To self-certify, you must meet ANY of the following criteria:
1.You are a Sole Proprietor AND a Minority Business Enterprise (MBE)
2.You are a Sole Proprietor AND a Woman Business Enterprise (WBE)
3.You are a Veteran Owned Business
4.You are a Service Disabled Veteran Owned Business
Instructions:
Diverse suppliers that qualify to self-certify please complete all sections below. Print, date and sign (noelectronic signatures will be accepted.) Then upload this form intoCVM systemor email to or fax to 630-206-1662. Any questions related to this form please contact us via email at.
Company’s Legal Name / NAICS Code
DBA/AKA Name / D&B Number
Current Address / Phone Number
City / State / Zip code / Fax Number
Remit To Address / Web Site
City / State / Zip code / Email Address
Business Owner Name(s) / # of Employees
Annual Sales
Principal Email Address
Business Classification / Ethnicity:
Sole ProprietorshipMinority Business Enterprise (MBE)or
Women Business Enterprise (WBE).
Definition: For a business to be classified as a sole proprietorship, the business must be unincorporated and have only one owner. . / African AmericanAleuts
Asian
Asian Pacific American Hispanic American Native (Indian) American
Caucasian
Veteran Owned Business
Service Disabled Veteran Owned Business
Definition: 51% or greater owned, managed and controlled by one or more veterans.
Gender Male Female Business Size Small Large
Definition: A small business is a business that is classified as “small” under the guidelines set forth by the Small Business Administration. Business size is dependent on the NAICS code, the number of employees, and the annual sales of a given company. Please refer to for more details.
IMPORTANT NOTICE - Under 15 U.S.C. 645(d), any person who misrepresents a firm’s status as a small business in order to obtain a subcontract that is to be included as part or all of a goal contained in a subcontracting plan required pursuant to Section 8(d) of the Small Business Act, shall (1) be punished by imposition of a fine, imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Act
The undersigned declares the foregoing statements are true and correct.
Executive Officer Name:
Executive Officer Signature: / ______
Title:
Date:
Notes: