Company Name*Address*
City*
State*
Zip*
DUNS Number
EIN Number*
Section A: Business Size*
Select the classification of your business: (Contact the nearest U.S. Small Business Admin.office (SBA) for guidance if you have questions) – Please check one:
Large BusinessSmall Business
Section B: Organization/Ownership*
Please check all that apply (If any of the below are checked, please attach a copy of the approved certificates, otherwise mark as self-reported.)
NoneWomen Business Enterprise (WBE)Small Disadvantaged Business (SDB)Disabled OwnedLesbian, Gay, Bisexual, Transgender (LGBT)HUBZone8(A) DesignationDisadvantaged Veteran Enterprise (DVE)Disabled Veteran Business Enterprise (DVBE)Service Disabled Veteran (SDV)Veteran Business Enterprise (VBE)Disadvantaged Business Enterprise (DBE)Vietnam VeteranOther

Section C: Minority Groups*
Minority-Owned Business (A for-profit business that is at least 51% owned by one or more of the following ethnic minorities who control daily management of business.)
NoneAfrican AmericanIndian Subcontinent Asian AmericanAsian Pacific AmericanHispanic AmericanNative AmericanMulti-CulturalOther
Certification Type*
Self ReportedCertifiedNone
Certifying Organization Name:*
National Minority Supplier Development Council (NMSDC)Canadian Aboriginal Minority Supplier Council (CAMSC)Women’s Business Enterprise National Council (WBENC)Other
Certification NumberExpiration Date
This will certify that the classifications I have selected are true and correct. Under 15 U.S.C. § 645 (d), any person who misrepresents the status of any concern or person may (1) be subject to 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.*
I Acknowledge