Business Size Self-Certification Form
Company Name:
Address:
City, State, Zip:
Contact Person:
Phone:
Fax Number:
Please check all that apply.
Small Business
Self-Certified as a Small Disadvantaged Business
Certified a SBA as a Small Business
Certified by SBA asbyHUBZone Small Disadvantaged Business
Certified by Business
Woman-Owned SmallSBA as a Small Disadvantaged Business
Certified by Business
Veteran-Owned SmallSBA as a Small Disadvantaged Business
Certified by SBA as a Small Disadvantaged Business
Service-Disabled Veteran Owned Small Business
Certified by SBA as an 8(a) Small Disadvantaged Business
Large Business (includinganon-profit)
Certified by SBA as Small Disadvantaged Business
Alaskan Native Corporation
Indian Tribe
Certified by SBA as a Small Disadvantaged Business
Other: Specify by SBA as a Small Disadvantaged Business
Certified
North American Industry Classification System Code (NAICS): (Please list PRIMARY code only that applies specifically to goods being
provided and/or services being performed).
You may wish to review the definitions for the above categories in the Federal Acquisition Regulation 19.7 or 52.219-9
(www.arnet.gov/far). If you have difficulty ascertaining your size status, please refer to SBA’s website at www.sba.gov/size or
contact your local SBA office.
You should register your business with the Small Business Administration @ www.ccr.gov.
Helpful websites:
a. SBA Size Table Standards: http://www.sba.gov/idc/groups/public/documents/sba_homepage/serv_sstd_tablepdf.pdf
b. North American Industry Classification System Codes: http://www.census.gov/epcd/naics02/
c. For additional help, contact the Small Business Administration (SBA) at www.sba.gov or 1 800 U ASK SBA (1 800 827 5722)
PENALTY FOR FALSE MISREPRESENTATION
Under 15 U.S.C. 645(d), any person who misrepresents its size status shall (1) be punished by 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.
Date
This document must be signed by a duly authorized representative confirmation of your company as a Small Business Concern per
the above standards.
Forward confirmation to Max Rutherford @ e-Mail: max.rutherford@gsdm.com or fax number: 512 242 7832.
Signature:
Title:
Date:
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