ROCKLAND COUNTY SMALL BUSINESS SELF-CLASSIFICATION FORM

ROCKLAND COUNTY SMALL BUSINESS SELF-CLASSIFICATION FORM
For purposes of the Procurement Policy of the County of Rockland, a "small business" shall refer to any commercial entity located physically within the geographic borders of the County of Rockland that employs from zero up to and including nine employees, including sole proprietorships, with a gross annual revenue of less than $1,000,000.
Company Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company Representative*
Name & Title
Phone Number*

Area CodePhone Number
E-mail
Website URL
Company website address
EIN / SSN*
Do no include spaces or dashes
NAICS Code(s)
Description of Goods and/or services available from the company*
Other Government Business Classifications Held:

NYS-MWBE – New York State Certified Minority or Woman Owned BusinessMWBE – Certified Minority or Woman Owned Business (other states)FTA Disadvantaged Business EnterpriseSmall Business ConcernSmall Disadvantage Business ConcernWoman-Owned Business ConcernVeteran-Owned Business ConcernService Disabled Veteran-Owned Business ConcernOther
To obtain small business size standards, go to the Small Business Administration’s website at http://www.sba.gov/size/
Additional documentation required to be submitted with this form:

Please scan and attach required documents to this form.
If you are unable to submit the required documentation with this form please check the box below. You must hand deliver the necessary documentation within 10 days of submitting this form.
I am unable to submit the required documentation electronically.
‌NOTICE:

You‌ must‌ hand‌ deliver‌ the‌ necessary‌ documents‌ to‌ the‌ Rockland‌ County‌ Purchasing‌ Department‌ at‌ the‌ address‌ below‌ within‌ 10‌ days‌ of‌ the‌ signature‌ date‌ at‌ the‌ bottom‌ of‌ this‌ form.

Rockland‌ County‌ Purchasing‌ Department
50‌ Sanatorium‌ Road,
Bldg‌ A,
Pomona,‌ NY‌ 10970

Phone: ‌ 845-364-3820
Fax: ‌ 845-364-3809
Hours: ‌ Monday‌ -‌ Friday‌ ‌ 8:00am‌ -‌ 5:00pm
1. Completed IRS Form 940 for prior year or other documentation to validate the total employees meet the stated requirement.*

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2. Valid Certificate of Incorporation as issued by NYS Department of State, Division of Corporations, State Records and Uniform Commercial Code or other documentation to validate the proposed firm has a commercial business office operating within the geographic borders of the County of Rockland.*

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3. The last fiscal year Financial Statement or other financial report within the last fiscal year showing the firm’s Annual Gross Revenue does not exceed $1,000,000.00*

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Representative Signature:
I hereby certify that the information provided to qualify as a Rockland Small Business is true and correct.
Print Name*
Print Title*
Date*

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Date
Signature*
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ROCKLAND COUNTY SMALL BUSINESS SELF-CLASSIFICATION FORM

Additional documentation required to be submitted with this form:

‌NOTICE:

Representative Signature: