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                          Contracting Opportunities Program
                   Small Contractors and Suppliers (SCS) Certification
   **Submitting A Complete Packet:
     Include the following: (Check all Boxes and include this page in your packet *= REQUIRED Documents)
        - *This Page (complete checkboxes)
        - *Application pg.1 - Company Profile           view page
        - *Application pg.2 - Signature Page (Signature Required)            view page
        - *Statement of Personal Net Worth (Signature Required)             view page
        - *Additional Statement of Personal Net Worth only if there are additional owners (Signature Required)                  view
        - *Copy of Federal Tax Statements (all pages) for the past three years (if applicable)
     ** To print all pages click file => print => in the print what box (bottom left) select entire workbook => click ok; this will
     print all pages at one time.

     Mail or Deliver to: Business Relations and Economic Development
                           400 Yesler Way, Suite 510
                           Seattle, WA 98104


   King County Review Process:
     Once your application is received:
     - it is reviewed for completeness
     - if all documentation is complete and forms have been submitted you will receive an email stating that the
       review process has begun and will be complete in approximately 30 business days. Once your firm has been
       accepted in the program you will receive a letter of acceptance and SCS ID number.
     - If your application is not complete the review process will stop and you will receive an email listing the
        required corrections. Once the corrections have been submitted to review process will begin again.
     - At anytime the certifying officer may request additional information or documentation to verify business and owner
     statement of personal net worth information
     - If for any reason your application is denied, the applicant will be removed from the certification process and be
     required to wait one year from the date of the denial notification before reapplying for certification.


   About the Program:
   The King County Contracting Opportunities Program was developed to create opportunities for King County and its
   contractors to make use of Small Contractors and Suppliers (SCS) firms on publicly advertised county contracts and
   increase the competitiveness of these firms as: Prime Contractors and Subcontractors; Consultants; and Suppliers.


   Program Benefits by Contract type:
    The following program benefits will apply to county contracts for:
    • Goods & Services - Incentive: 5% Fair Market Range to rank SCSs for evaluation purposes
    • Consulting Services - Incentive: Award of Points for the use of SCS Firms
    • Construction          - Requirement: Participation requirement for SCS firms

   Eligibility Criteria:
    Each Owner:
     - Personal net worth less than $750K (excluding primary residence)
    Business Size:
     - 50% of the SBA business size standards      click to access SBA Standards based the company's industry
    classification (NAICS Code) click to find your NAICS Code
    Training:
     - Agreement to participate in 15 hours of technical assistance/business development

Print and Submit this page with your application packet
v.1006.004                               Business Development and Contract Compliance Section                                          1
                                        King County Contracting Opportunities
                                                Program Application
Company Profile:
Company Name*
Certification Type*             -SELECT-                        If ReCertification then Enter SCS #
Employer Identification Number*
(Federal Tax Id)
WA State UBI Number*
(Unified Business Identification)

Doing Business As                                                                                     0
Address*
Suite
City State Zip*                                                                  WA      zip code
Company Phone Number*
Company Web Site
Business Locale*                    -SELECT-
Owner Gender
Owner Ethnicity                     -SELECT-
Owner Disabled                      -SELECT-
Contractor License Number
Number of Employees
Company Description*




Contact Person: (directory listing)
First Name*
Last Name*
Title
Email*
Phone*

Contracting Type: (select at least one*)
Architectural Engineering        -SELECT-
Construction                     -SELECT-
Goods and Services               -SELECT-
Professional Consulting          -SELECT-
Technical Consulting             -SELECT-

North American Industry Classification System:
NAICS Code Primary*           -SELECT-
NAICS Code 2nd                -SELECT-
NAICS Code 3rd                -SELECT-
NAICS Code 4th                -SELECT-
NAICS Code 5th                -SELECT-

CSI Classification: (construction only)
Primary discipline                -SELECT-
secondary discipline              -SELECT-
additional discipline             -SELECT-
additional discipline             -SELECT-
additional discipline               -SELECT-



v.0901.001                          Business Development and Contract Compliance Section                  Page 2
                                            King County Contracting
                                        Opportunities Program Application
                                                    (continued)
Business Type:
Business Structure*                  -Select-
If Other is selected explain         [Explanation if needed]

Annual Gross Receipts - past 3 years (if applicable): Include Complete Tax Statements with application
Number of years in business          -Select-
-Select Year-                         $                                                                  -
-Select Year-                         $                                                                  -
-Select Year-                         $                                                                  -
         3 year average               $                                                                  -

Ownership:
Is any percentage of this company owned by another corporation?*                       -Select-
Select ownership type*                                                                - Select -
List of Owners:
                                                                                                     % of
             Last Name                     First Name           Initial           Title            ownership




Please add a supplemental document if you need to add additional Owners (each owner must
complete the Statement of Personal Net Worth form)

Business Training Agreement:
Upon certification I agree to complete the required 15 hours of business training                   -Select-

Training Information:
The Contracting Opportunities Program requires that all participants complete 15 hours of business
development training within the 1st year of certification

Types of training include:
         Vendor Training               Continuing Education Classes           Online Business Training
     Business Workshops                University/Technical Classes             Networking Events

Additional Certifications:           Type:                                            Number:
WA State                             -Select-                                         [Enter Number]
Federal                              -Select-                                         [Enter Number]
Small Business Administration        -Select-                                         [Enter Number]
Additional Certifications:           [Enter Type]                                     [Enter Number]
Additional Certifications:           [Enter Type]                                     [Enter Number]

Declaration Agreement:
I recognize that the information submitted in this application is for the purpose of inducing
certification approval by a government agency. I understand that a government agency may, by means
it deems appropriate, determine the accuracy and truth of the statements in the application, and I
authorize such agency to contact any entity named in the application, and other certifying agencies for
the purpose of verifying the information supplied and determining the named firm’s eligibility.


I agree to submit to government audit, examination and review of books, records, documents and files,
in whatever form they exist, of the named firm and its affiliates, inspection of its places(s) of business
and equipment, and to permit interviews of its principals, agents, and employees. I understand that
refusal to permit such inquiries shall be grounds for denial of certification.

I declare under penalty of perjury that the information provided in this application and supporting
documents is true and correct.


SIGNATURE:                                                            DATE:
                      (Owner / Certifying Agent)
v.0901.001                                 Business Development and Contract Compliance Section                Page 3
                                                                                ATTACHMENT "A" STATEMENT OF
                                                                                    PERSONAL NET WORTH



    Instructions:
     * Complete each field based on Total Value of Assets and Liabilities; if Married Assets and Liabilities will be divided by
     2, to determine the Owners Personal Net Worth.
     * Each individual owner is required to complete the form. If owners are married, submit a form for each person.
     * All fields require a response; if the form is submitted incomplete the certification process will be delayed.
     * Once the form is complete Print and Sign (if married, spouses signature is required)


    Company Name
    Name of Owner                                          [First Name]                          [Last Name]
    Owners Primary Residential Address
    Suite
    City State Zip                                         [Enter City]                          WA               zip code

    Marital Status
    Owner is Married                                       -Select-
    If yes [Enter Spouses Name]                            Not Applicable                        Not Applicable

    Section 1 - Cash Assets                                (for any field which does not apply - insert N/A)
    Cash on Hand                                            $                                                                       -
    Checking Accounts                                       $                                                                       -
    Savings Accounts                                        $                                                                       -
    Retirement Accounts                                     $                                                                       -
    Notes Receivable                                        $                                                                       -

    Cash Liabilities                                       (for any field which does not apply - insert N/A)
    Accounts Payable                                        [Enter type of Liability]                             $                 -
    Notes Payable                                           [Enter type of Liability]                             $                 -

    Section 2 - Life Insurance (Cash/Surrender Value only)                (for any field which does not apply - insert N/A)
    [Enter Name of Insurance Company]               $                                                                               -
    [Enter Name of Insurance Company]               $                                                                               -
    [Enter Name of Insurance Company]               $                                                                               -
    Total                                           $                                                                               -

    Section 3 - Stocks and Bonds                           (for any field which does not apply - insert N/A)
                                                            Number       Market Value   Date of Quote
    Name of Security (e.g. Microsoft)                      of Shares Quotation/Exchange / Exchange                    Total Value
    [Enter Name of Security]                                       0 $                -                           $                 -
    [Enter Name of Security]                                       0 $                -                           $                 -
    [Enter Name of Security]                                       0 $                -                           $                 -
    [Enter Name of Security]                                       0 $                -                           $                 -
    Total                                                  $                                                                        -
    List additional securities if any on separate sheet of paper (use above format)
    **Include this page with application packet




v.0901.001                               Business Development and Contract Compliance                                                   4
                                                                              ATTACHMENT "A" STATEMENT OF
                                                                                  PERSONAL NET WORTH



    Section 4 - List of Properties                          (for any field which does not apply - insert N/A)
    Primary Residence                                       -Select Type-
    Owners Primary Residential Address                                                                                           0
    Suite                                                                                                                        0
    City State Zip                                          [Enter City]                       WA               zip code         0
    Date Purchased
    Purchase Price
    Current Market Value                                     $                -          Mortgage Balance       $            -

    Additional Property                                     -Select Type-
    Address
    Suite
    City State Zip                                          [Enter City]                       WA               zip code
    Date Purchased
    Purchase Price                                           $                                                               -
    Current Market Value                                     $                -          Mortgage Balance       $            -

    Additional Property                                   -Select Type-
    Address
    Suite
    City State Zip                                        [Enter City]                    WA                    zip code
    Date Purchased
    Purchase Price                                         $                                                                 -
    Current Market Value                                   $               -        Mortgage Balance            $            -
    List additional properties if any on separate sheet of paper (use above format)

    Section 5 - Vehicles                                    (for any field which does not apply - insert N/A)
    Year of Vehicle                                                  Make                    Model                   Value
                                                                                                                $            -
                                                                                                                $            -
                                                                                                                $            -
                                                                                                                $            -
    Total                                                    $                                                               -

    Section 6 - Additional Assets                           (for any field which does not apply - insert N/A)
    Household Furnishings / Personal Goods
    (e.g. watches, Jewelry, art etc.)                        $                                                               -
    Equity in business to be certified
    (not a factor of personal net worth)                     $                                                               -
    Additional Business Ownership/Equity (do not
    include the business which you are applying for SCS)     $                                                               -
    Total                                                    $                                                               -

    Section 7 - Other Liabilities                           (for any field which does not apply - insert N/A)
    Credit Cards                                             $                                                               -
    Home Equity Loans                                        $                                                               -
    Personal Loans                                           $                                                               -
    Vehicle Loans                                            $                                                               -
    Any other loan / liability                               $                                                               -
    Total                                                    $                                                               -
    **Include this page with application packet




v.0901.001                                    Business Development and Contract Compliance                                           5
                                                                             ATTACHMENT "A" STATEMENT OF
                                                                                 PERSONAL NET WORTH



    Transfer of Assets =============> Have you transferred personal Assets in the last 12 Months        -Select-
                                                     Asset One             Asset Two             Asset Three
    Description of Asset transferred
    To whom transferred
    Relationship to transferee
    Purpose of Transfer
    Date of Transfer
    Value of Asset at time of transfer
    Consideration received for transfer



    Notification / Agreement:
     Under penalty of perjury, I certify I have listed all assets which I own on this document and that all statements on this
     document are true and accurate as of the stated date. I authorize certifying agency to make inquires as necessary to verify
     the accuracy of the statements made and to determine my certification eligibility. I certify the statements contained in this
     document are true and accurate as of the stated date. These statements are made for the purpose of obtaining
     certification in the King County Contracting Opportunities Program (SCS Certification). I understand FALSE statements may
     result in rejection of certification, and or future decertification if FALSE statements are discovered after acceptance in th e
     program. I agree to submit an updated personal net worth form upon application of recertification or within 30 days of
     substantial change in any statement provided for certification.




    Signature (business owner)                                                                                Date


    Signature (Owner's Spouse if listed marital status as yes above)                                          Date
    Print and Submit this page with your application packet




v.0901.001                              Business Development and Contract Compliance                                                   6

								
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