Supplier Diversity Self-Certification

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Legal Company Name

Federal Tax ID #

DBA/AKA Name

NAIC Code(s)

DUNS Number

Annual Revenue ($)

Number of Employees

Owner's Name

Owner's E-mail *

Phone

Physical Address

City

State

ZIP

Business Size

Large
Small

Business size is determined by NAICS code and number of employees or annual sales. To determine if your company is a Small Business, please visit the SBA’s online Size Standards Tool at http://www.sba.gov/tools/size-standards-tool

Business Classification (check all that apply)

Small Business Categories

Small Business (SB)
Veteran-owned Small Business (VOSB)
Service Disabled Veteran-owned Small Business (SDVOSB)
SBA Certified 8(a) Small Business
Small Disadvantaged Business (SDB)
SBA Certified HUBZone Small Business (HUBZS)
Women-owned Small Business (WOSB)

Other Diverse Business Categories

Minority Business Enterprise (MBE)
Women’s Business Enterprise (WBE)
Alaskan Native-owned Business (ANC)
American Indian Tribe

Certifications (Please enter all certifications below that apply)

SBA Certification Exp. Date

SBA Certificate #

NMSDC Certification Exp. Date

NMSDC Certificate #

WBENC Certification Exp. Date

WBENC Certificate #

VetBiz Certification Exp. Date

VetBiz Certificate #

Other Certification Info

The undersigned declares the above statements are true and correct. 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.

Signature *

Clear Signature

Print Name / Prepared By

Title

Date

TF_920_0000_0844_01

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Techmetals, Inc.

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