Declaration of Certification

Small Business & Local Preference Program
(District of Columbia, State of Maryland or Commonwealth of Virginia)

This application will not be considered unless the applicant has registered in the Vendor Registration System. Each applicant should use Metro's Material Category Codes to identify their areas of expertise. Upon completion of the online "Declaration of Certification" affidavit, applicants must print, sign, and notarize the document and mail the original to:

Necola Y. Shaw
Coordinator, Small Business and Local Preference Program
Office of Procurement & Materials
Washington Metropolitan Area Transit Authority
600 5th Street, NW
3B-14
Washington, DC 20001

Business Profile

Name of Business:
Business Address:
City:
State:
Zip Code:
Business Telephone:
Fax:
FEIN:
Business Owner's Name
Title:
Email Address:
Percentage (%) of Ownership:
Have you registered in the Vendor Registration System: Yes   No
(Note: Bidders/Vendors must complete this process first)
Website:
Year Established:
Other Contact Name:
Title:
Telephone Number:
Email Address:
Number of Full Time Employees:
Number of Part Time Employees:
Dun & Bradstreet Number:
Legal Business Structure (Please check one):
Corporation Limited Liability Corporation (LLC) Partnership Sole Proprietorship
Provide the firm's annual gross receipts, before deducting expenses for the last three (3) years.
Year:Gross Receipts:
Year:Gross Receipts:
Year:Gross Receipts:
(Gross Receipts) Three Year Average:

I understand that Metro reserves the right to request U.S. Federal Corporate (or personal) income tax returns confirming gross receipts as well as certificates of incorporation issued by localities and/or states.

Metro's Material Category Codes

Use the Procurement & Contracting Material Category Codes for completing this section (e.g. A01001 - Abrasive Materials excluding Stone). List below as many as 12 Material Category Codes that represent the primary good(s) and/or service(s) provided by your firm. These Material Category Codes should be the same codes that you have used in registering your firm in the Vendor Registration System. If you elect to use more than 12 codes that appropriately define your products or services, an additional sheet may be attached to this document.

 Code Number - Code Description Code Number - Code Description
1. 7.
2. 8.
3. 9.
4. 10.
5. 11.
6. 12.

Affiliates to Your Firm

An affiliate is an individual or concern that has the power to control the firm, or a concern over which the firm has power to exercise control, including indirectly or through a third-party, considering factors such as ownership, management, and previous relationships including contractual relationships as further defined in U.S Small Business Administration (SBA) 13 Code of Federal Regulations (CFR) Subsection(s) 121.103(1)-(6).

List the following for any foreign or domestic affiliate of your firm during the last three (3) calendar years:

a)Name:
b)Date the affiliations began and ended:
c)Number of employees:
d)Percentage (%) of ownership by the affiliate of the firm and/or by the firm of the affiliate:
e)Average gross receipts of the affiliate:
f)FEIN for each affiliate:

A separate sheet may be used to outline other affiliates.

No Affiliates (Please check , if applicable)


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