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FIRM NAME: DIV OF: ADDRESS: CITY, STATE, AND ZIP: Telephone: Email and/or web address:

PRIMARY NAICS CODE:

Fax:

PLEASE COMPLETE THE AREA BELOW Business Classification: Small Business Large Business

Business Classification: (See reverse side of cover letter for definitions and then check all that apply): Small Disadvantaged Business Service Connected Disabled Veteran Owned Certified Minority Business Enterprise Alaska Native Corp & Indian Tribe Small Business Certifying Agency(s): Certificate No. and Expiration Date: Federal Tax I.D. # or SSN: Annual Revenue Range: (Please check one): $0 - $100,000 Type of Business: Broker Manufacturing Products and Services Data: Other NAICS Codes: Description of Products or Services: PLEASE SIGN AND DATE BELOW Under 15 U.S.C. 645(d), any person who misrepresents its size status shall (1) be punished by fine, imprisonment, or both; (2) be subject to remedies: and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act. Retailer Wholesaler Construction Contractor Other Services Professional Services Other $100,000 - $500,000 $500,000 - $1,000,000 $1,000,000 - $3,000,000 Over $3,000,000 # of Employees: DUNS Number: Veteran Owned Woman Owned Certified Women Owned Business Enterprise Alaska Native Corp & Indian Tribe NOT a Small Business HUB Zone (SBA Certified) Texas HUB

Signature and Title CONTACT NAME (Please Print): CONTACT PHONE NUMBER: TITLE: E-MAIL ADDRESS:

Date

This self-certification is valid for a 12-month period from the signature date on the form. It is your responsibility to notify us if your company's size or ownership status changes during this period. AREA BELOW FOR INTERNAL USE ONLY Vendor Code: HUB Zone Status Verified SBA indicator code entered as on / / By:

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