Small Business Self-Certification Form
Please Complete and Email This Form To:
Nicki Viecelli, Marketing Administrative Assistant
Email:
Fax: 619-308-9334
Street Address/City/State/Zip Code:
Phone/Fax:
Email:
Point of Contact (Name/Title):
How did you find out about RECON?
Please list a description of services, geographic locations served, and any permits for various endangered species:
Please list NAICS Codes under which you are a small business:
Are you registered as a small business on the federal CCR (Central Contractors Registration) database or SBA’s DSBS (Dynamic Small Business Search)? Please check all that apply: CCR DSBS
Please check all that apply:
Federal Classifications:Small Business (SB)
Small Disadvantaged Business (SDB)
8(a)
Woman-Owned Business (WOB)
HUBZone Small Business(HUBZone)
Service Disabled Veteran-Owned Small Business (SDVOSB)
Veteran-Owned Business (VOB)
Historically Black Colleges and Universities/Minority Institutions (HBCU/MI)
Other (please describe): / Certifications from Non-Federal Agencies (please list name of certifying agencies): *For definitions of the non-federal classification below, please refer to the certifying agency’s definition of that specific classification.
Women Business Enterprise (WBE)
Certifying agency:
Disabled Veteran Business Enterprise (DVBE)
Certifying agency:
Minority Business Enterprise (MBE)
Certifying agency:
Disadvantaged Business Enterprise (DBE)
Certifying agency:
Small Business Enterprise (SBE)
*See page 2 of this form for SBA small business classification definitions. / Certifying agency:
Underutilized Disadvantaged Business (UDBE)
Certifying agency:
I certify under penalty of perjury that the above information is correct and have referred to the second page of this form to confirm my small business classifications with the definitions provided, and that I am authorized to sign this form on behalf of this company.
Please use an electronic signature, if you do not have this capability, please sign, scan, and email or fax this document back to Nicki Viecelli. Thank you
Signature: / Title: / Date:Definitions of SBA Small Business Classifications
1) Small Business (SB): A small business is a concern that is organized for profit, with a place of business in the United States, and which operates primarily within the U.S. or makes a significant contribution to the U.S. economy through payment of taxes or use of American products, materials or labor. Further, the concern cannot be dominant in its field, on a national basis. Finally, the concern must meet the numerical small business size standard for its industry. SBA has established a size standard for most industries in the U.S. economy.
2) Small Disadvantaged Business (SDB): A small business concern that is at least 51 percent owned by one or more individuals who are both socially and economically disadvantaged. This can include a publicly owned business that has at least 51 percent of its stock unconditionally owned by one or more socially and economically disadvantaged individuals and whose management and daily business is controlled by one or more such individuals.
3) 8(a) Firm: A firm owned and operated by socially and economically disadvantaged individuals and eligible to receive federal contracts under the Small Business Administration’s 8(a) Business Development Program.
4) Woman-Owned Small Businesses (WOB): A woman-owned small business concern means a small business concern-(a) which is at least 51 percent owned by one or more women; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and (b) whose management and daily business operations are controlled by one or more women.
5) Historically Underutilized Business Zone (HUBZone) Businesses: The HUB-zone Empowerment Contracting program provides federal contracting opportunities for qualified small business located in distressed areas. Fostering the growth of these federal contractors as viable businesses, for the long term, helps to empower communities, create jobs, and investment.
6) Service-Disabled Veteran-Owned Small Business (SDVOSB): A SDVOB is a concern that is (1) at least 51% owned directly and unconditionally by a service-disabled veteran and (2) managed and controlled by a service-disabled veteran, or spouse or permanent caregiver of a service-disabled veteran with a permanent and severe disability.
7) Veteran-Owned Small Business (VOB): is defined as a business that is owned 51% by a veteran(s). There is no veteran-owned certification process to complete; simply self-certify by checking the appropriate box. Learn more at SBA’s Office of Veterans Business Development (OVBD).