SOUTHERN PLAINS INDIAN PREFERENCE BOARD

P.O. BOX 788

ADA, OK. 74821

580-272-5400

SUB-CONTRACTOR PROCESSING FEE: $ 50.00,______NOTE: Form must be accompanied by GENERAL CONTRACTOR $150.00, ______annual processing fee in order to be PROFESSIONAL PROCESSING FEE: $ 150.00, ______reviewed by the SPIPB.

PLEASE,Check markwhat you applied for when you became a member of the SPIPB.

SUBMIT: ORIGINAL AND 10 COPIES OF APPLICATION; CURRENT ENROLLMENT/CITIZENSHIP CARD WITH PHOTO AND COPY OF DRIVER’S LICENSE

INDIAN PREFERENCE PRE-QUALIFICATION BOARD

RE-CERTIFICATION STATEMENT

I/WE hereby certify that there has not been any significant change of structure or ownership of the following:

NAME OF ENTERPRISE

______

ADDRESS CITY STATE ZIP

______

TELEPHONE TRADE OR SPECIALITY

Since I/WE were last pre-qualified by the Southern Plains Indian Preference Pre-Qualification

Board on ______.

DATE OF CERTIFICATION

Signed:______

MAJORITY OWNER TELEPHONE DATE

Print Name: ______

Signed: ______

CONTRACTING OFFICER TELEPHONE DATE

Print Name: ______

*** SIGNATURE AND NOTARY DATES MUST COINCIDE.***

IN WITNESS WHEREOF the party(s) have affixed ______hand(s) the date and year first above written.

Subscribed and sworn to before me this ______day of ______, 2016.

My commission expires: ______Commission # ______

Notary Public: ______

WARNING: U.S. Criminal Code, Section 1010, Title 18 U.S.C., provides in part: (SEAL)

“Whoever,…makes, passes, utters, or publishes any statement, knowing

the same to be false…shall be fined not more than $5,000 or imprisoned

not more than two years, or both.”

NOTES:

  1. Omission of any information may cause for this statement not receiving timely consideration.
  1. Knowing that the Department of Housing and Urban Development must approve a contract between this enterprise and the Indian housing authority, the persons signing below certify that all information in this Indian Preference Qualification Statement, including exhibits and attachments, is true and correct.
  1. Print or type all names below signatures.

If applicant is sole proprietor, sign below:
______

By:

Print: ______

All partners must sign below:

______
By:Date:

______

By:Date:

______
By:Date:

______

By:Date:

If applicant is a corporation, affix corporation seal.

______
Corporation SealDate:

By: ______
President’s signature

Attested by: ______
Corporation Secretary’s signature

IN WITNESS WHEREOF the party(s) have affixed ______hand(s) the date and year first above written.

Subscribed and sworn to before me this ______day of ______, 20_____.(SEAL)

My commission expires: ______Commission #: ______

Notary Public: ______

Warning: U.S. Criminal Code, Section 1010, Title 18 U.S.C., provides in-part: “Whoever…makes, passes, utters, or publishes any Statement, knowing the same to be false…shall be fined not more than $5,000 or imprisoned not more than two years, or both.”