SII Self-Certification Form

SII SELF-CERTIFICATION FORM

COMPANY INFORMATION

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

Legal Company Name

DBA/AKA Name

Physical Address

City State Zip Code

Remit To Address

City State Zip Code

Owner’s Name

Owner’s Email Address

NAICS Code(s)

Federal Tax ID

D&B Number

Phone Number

Fax Number

Website

Annual Revenue

Number of Employees

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

BUSINESS CLASSIFICATION (Check all that apply)

If there is a star by the name of the classification, a copy of the certification must be included.

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

☐Small Business Enterprise (SBE)

☐Small Disadvantaged Business (SDB)

☐Disadvantaged Business Enterprise (DBE)

☐Disabled Owned Business

☐Women Business Enterprise (WBE)*

☐Woman-Owned Small Business (WOSB)*

☐Economically Disadvantaged Women-Owned Small Business (EDWOSB)

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

☐Veteran-Owned Small Business (VOSB)*

☐Minority Business Enterprise (MBE)*

☐8(a) Certified Business*

☐Historically Black Colleges and Universities (HBCU)

☐Historically Underutilized Business Zone (HUBZone)*

☐Alaskan Native Owned Business (ANC)*

☐AbilityOne Program (JWOD)

☐Native American Tribes (NAT)

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

CERTIFICATIONS

If there is a star by the name of the classification, the below certifying agency information must be completed with a copy of the certification.

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

Certifying Agency / Certificate Expiration Date / Certificate Number
☐Small Business Administration (SBA)
☐National Minority Supplier Development Council (NMSDC)
☐Women’s Business Enterprise National Council (WBENC)
☐Veteran Affairs Office
☐Other

REGISTRATION

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

☐SAM.gov

☐Yes Registration Expiration Date

☐No

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

(As required by FAR 52.204-8, Supplier represents that the annual Representation and Certification is current.)

☐State Registrations

BUSINESS SIZE

Business size is dependent on NAICS code and number of employees or annual sales. For more information, refer to www.sba.gov/tools/size-standards-tool

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

☐Small ☐Large

OWNER ETHNICITY

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

☐African American (Black)

☐Asian Pacific

☐Asian Subcontinent (Asian Indian)

☐American Indian or Alaskan Native

☐Caucasian

☐Hispanic

☐Pacific Islander

☐Other

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

OWNER GENDER

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

☐Male

☐Female

Document Number: B01_99_FM0176 Department: Procurement Date: 05/30/2014

Version: 1.0 Document Owner: Liza Sharkey Page 1 of 1

STATEMENT

The undersigned declares the above statements are true and correct. Please provide a real signature, not an electronic signature.

NOTICE: Under 15 U.S.C. 645(d), any person who misrepresents a firm’s size or disadvantaged status to obtain a federal contract or subcontract 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 Small Business Act.

Prepared By

Signature
Title

Date