DM Selfcertification

SUPPLIER DIVERSITY SELF-CERTIFICATION FORM
The following information is being requested on behalf of Diversified Maintenance. In support of our Supplier Inclusion Program, Diversified Maintenance is required to maintain certification of business size and ownership from all of its suppliers. Your participation in reporting this information is important for ensuring successful relationships among all members of the business community.
Legal Company Name*
Business Owner Name*
DBA / AKA Name is:*
Business Owner Email Address:*
Address:*
# of Employees:*
Fed Tax ID or SSN (if Individual):*
Annual Sales:*
City, State, Zip Code:*
Business Classification (check all that apply)*

Minority Business Enterprise (MBE)Women Business Enterprise (WBE)Veteran Business Enterprise (VBE)Service-Disabled Veteran Business Enterprise (SDVBE)LGBT Business Enterprise (LGBTBE)Disability-Owned Business Enterprise (DOBE)Historically Underutilized Business (HUB Zones)Small Disadvantaged Business (SDB)8(a) Certified Business
Ethnicity (check all that apply)

African AmericanAsianHispanic AmericanNative AmericanAsian Pacific American
iF ANY OF THESE ARE NOT APPLICABLE, CLICK THIS BOX
Business Size*

SmallLarge
Definition: A small business is a business that is classified as “small” under the guidelines set forth by the Small Business Administration. Business size is dependent on the NAICS code, the number of employees, and the annual sales of a given company. Please refer to http://www.sba.gov/size for more details.
Certification as a Diverse Business
If applicable, indicate the agency from which your company has been certified as a diverse business or as a small business enterprise.

		Certification Expiration Date	Certificate Number
Small Business Administration
NMSDC
WBENC
NVBDC
NGLCC
Disability:IN
Other:

Please upload your Diversity Certificate

Browse Files

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The undersigned declares the foregoing statements are true and correct.
Prepared By:*
Signature:*
Date*

MonthDayYear
Title:*
IMPORTANT NOTICE - Under 15 U.S.C. 645(d), any person who misrepresents a firm’s status as a small business in order to obtain a subcontract that is to be included as part or all of a goal contained in a subcontracting plan required pursuant to Section 8(d) of the Small Business Act, 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 Act.
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SUPPLIER DIVERSITY SELF-CERTIFICATION FORM

Certification as a Diverse Business

The undersigned declares the foregoing statements are true and correct.