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 General Information 
 Company Name  NAICS or SIC Code
 DBA/AKA Name  Federal Tax ID or SSN
 Current Address  D&B Number
 Phone Number
 City   State   ZIP   Fax Number
 Remit-To Name  Website
 Remit-To Address  Email Address
 # Employees
 Annual Sales
 Business Classification (select all that apply) 
 Sole Proprietorship  Publicly Ownedticker code: 
 Limited Partnership  Privately Owned
 General Partnership  Non Profit Organization
 Corporation  
 Independent  Local Supplier
 Division of Above Named Parent  Regional Supplier
 Subsidiary of Above Named Parent  National Supplier
 Affiliate of Above Named Parent  Multi-National Supplier
 Country of Ownership (select one) 
 U.S. Owned: A business is considered U.S. Owned if the basic contractual and legal responsibilities for its operation reside within the U.S., its territories or possessions.  Foreign Owned
 Business Size 

 Large  Small		 Definition: A small business is a business that is classified as "small" under the guidelines set forth by the Small Business Administration. Business size is dependent on the NAICS code, the number of employees and the annual sales of a given company. Please refer to http://www.sba.gov/size/ more details.
 Business Ownership (check all that apply) 


Small Disadvantaged Owned - A business that is at least 51% owned, managed and controlled by individual(s) identified as "minority." In the case of a publicly owned business, at least 51% of the stock must be owned and managed by minorities. (Must have certification through the SBA.)

 

 

 

   If Minority Owned, select one:
     African/Black American
     Asian Indian American
     Asian Pacific American
     Hispanic American
     Native American
     Other Minority - specify:
            
Minority Owned - A business that is at least 51% owned, managed and controlled by individual(s) identified as "minority." In the case of a publicly owned business, at least 51% of the stock must be owned and managed by minorities. (SBA certification is not required.)

 
Woman Owned - A business that is at least 51% owned, managed and controlled by individual(s) identified as "women." In the case of a publicly owned business, at least 51% of the stock must be owned and managed by women.

 
HUBZone Small Business - The term "HUBZone" shall mean a business that mets the following criteria: Must (1) be located in a "historically underutilized business zone,"; (2) be owned and controlled by one or more U.S. Citizens, and; (3) at least 35% of its employees must reside in a HUBZone. HUBZone Small Businesses must have certification from the Small Business Administration.

 
Veteran Owned - A business that is at least 51% owned, managed and controlled by individual(s) identified as "veteran." In the case of a publicly owned business, at least 51% of the stock must be owned and managed by veteran(s).

 
Service Disabled Veteran Owned - A business that is at least 51% owned, managed and controlled by individual(s) identified as "disabled veteran." In the case of a publicly owned business, at least 51% of the stock must be owned and managed by disabled veterans.

 
 Company Principals 
  Principal Name Title Percent Ownership
 Certification as a Small, Ethnic or Woman Owned Enterprise 
  If applicable, indicate the agency from which your company has been certified as an ethnic or woman owned enterprise,
  or as a small business enterprise, and attach a copy of your certification. COPY OF CERTIFICATION REQUIRED.
  Certification Date Specify Locality or Other Agency
  Small Business Administration
  NMSDC Affiliated Council
  Women's Business Enterprise Nat'l Council
  Other:  
  Other:  
 
 Diversity achieved by other means:  Sub-contractors  Employees
 CATV Provider Of   Type of Business 
  Accounting/Services Billing   Converter, Recovery   Power Supplies   Contractor
  Advertising   Converters   Print & Reprographics   Distributor
  Antennas & Towers   Courier Service   Promotion Products & Svc.   Factory Rep.
  Attorney/FCC Cable   Drop Material   Real Estate Related   Manufacturer
  Batteries & Accessories   EAS   Remote Control   Retail Dealer
  Cable, Fiber Optic   Electrical Services   Safety   Service Provider
  Cable, Drop   Electrical Supply   Salvage, Scrap Services   Value Added Reseller
  Cable, T&F   Electronics, Distribution   Security   Wholesaler
  Catering   Employment Services   Shredding Services   Other:
  Cleaning & Janitorial Svc.   Environmental Services   Signage
  Coffee/Vending Service   Fiber Optic, Splice Product & Tools   Storage
  Collection Service   Florist   Studio Equipment
  Computers   Furniture Dealer   Telemarketing
  Connectors   Glass   Test Equipment & Tools
  Construction, Aerial   Hardware, Cons.   Traps & Filters
  Construction, Design   Headend Equipment   Travel
  Construction, Fiber Optic   Landscaping   Uniforms
  Contstruction, Install   Locksmith   Vehicle, Upfitting
  Construction, General   Office Supplies & Products   Vehicle, Fleet Mgmt / Auto Dealer
  Construction, UG   Pest Control   Other:
  Converter, Parts & Repair   Plumbing, Heating & A/C
 Company Background
 Year this company began operation:
 Geographical Service Area(s):
 

IMPORTANT NOTICE
Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a small business in order to obtain a subcontract that is to be included as part or all of a goal contained in a subcontracting plan required pursuant to Section 8(d) of the Small Business Act, 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 Act. (FAR 52.219-1)


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