Business Size Representation

It is the policy of GovC that small businesses, small disadvantaged business concerns, woman-owned small businesses and HUBZone small businesses concerns have the maximum practicable opportunity to participate in the performance of contracts awarded to GovC. In order to comply with this policy, please provide the following information.

Seller’s Name:

Street Address:

City: McLean State: ZIP: Phone:

No. of Employees:

Remittance Address (if different from above) Street Address:

D&B Number:

Federal Tax ID No. (EID):

Payment Terms:

This company is: (check the ones that apply)__ A Division of: __ A Subsidiary of: __ An Affiliate of: __ Independently Owned and Operated __ Manufacturer __ Consultant __ Distributor ____ Retailer ____ Other:

Identify Major Supplies/Services and Primary Standard Industry (SIC) and North American Industry Classification System(NAICS) Codes Primary SIC Code: [] Primary NAICS: []

Business Size/Type (select one only) [ ] Small Business [ ] Large Business [ ] Foreign Owned (non US) [ ] Non-Profit

Business Ownership (select all that apply) [ ] Minority/Disadvantaged Business [ ] Woman-Owned Business [ ] Historically Black College/Minority Institute [ ] Service Disabled Veteran Owned [ ] HUBZone (certified by SBA) [ ] Veteran Owned

If Minority/Disadvantaged is selected above, please check the appropriate category in which business ownership falls: [ ] African American [ ] Asian Pacific American [ ] Hispanic American [ ] Native American [ ] Subcontinent Asian American [ ] Other than those listed

Authorized Signature: ______________________________ Title:

Name Printed: Date: _______________________

GovC may award a procurement to the seller where the costs will be charged to a U.S. Government prime or subcontract. If so, the seller is advised that the U.S. Government may impose a penalty against a firm misrepresenting its business size and/or disadvantaged status for the purpose of obtaining a procurement that is to be included as part, or all of a goal contained in GovC’s subcontracting plan. Eligibility as a small business is based on the regulations issued by the Small Business Administration in CFR 13, Part 121 of the SBA Rules and Regulations.