Supplier Self-Representation Form
In accordance with federal government and corporate policy requirements, many corporations are required to have
signed representation of business size and classification from suppliers. Please check all the applicable boxes below,
sign and return this form.
Company Name: __________________________________________________ DUNS# ________________________
Contact Name: _________________________________________ Title: ___________________________________
E-Mail Address: ___________________________________________________
Product or Service: ________________________________________________
Primary NAICs Code: __________________________________ (www.census.gov/epcd/www/naics.html)
Please check all applicable boxes:
Small Business: A business meeting the established criteria for qualifying as a small business concern in your industry
as defined by the Small Business Administration in 13CFR part 121, see FAR 19.102
(www.acquisition.gov/far/90-37/html/19.html )
YES
NO
Small Disadvantaged Business (SDB):
does
does not self-certify as a small disadvantaged business concern where the concern is owned by one or more
individuals claiming disadvantaged status, the net worth of each individual upon whom the certification is based does
not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2).
Veteran-Owned Small Business (VOSB):
does
does not self-certify as a Small Veteran-owned Business in which 51% of the ownership is held by one or
more Veterans (as defined in 38 U.S.C. 101(12) or, in the case of any publicly owned business, 51% or more of the stock
is owned by one or more Veterans; and the management and daily business operations are controlled by one or more
Veterans.
Service-Disabled Veteran- Owned Small Business (SDVOSB):
does
does not self-certify as a Small Service-disabled Veteran-owned Business owned by a Service-disabled
Veteran or Veterans (see above). To be further classified as Service-Disabled in accordance with 38 U.S.C. 10(12), the
Veteran or Veterans must have a disability/or disabilities that are Service connected as defined in 38 U.S.C. 101(16).
Certification is required by an authorized representative verifying the information submitted is true. In accordance
with 15 U.S.C 645(d), any person who misrepresents a firm’s proper size classification 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 Small Business Act. An updated Supplier SelfRegistration Form must be uploaded in the event of change of ownership and/or small business classification status.
Name:______________________________________________ Title: _________________________________
(print name and title)
Authorized Signature: _____________________________________________ Date: ________________________
(Void unless signed)
Document must be signed and uploaded into profile or sent to Diversity Information Resources (via email, fax or USPS): 2105 Central
Avenue NE, Minneapolis, MN 55418 Tel: (612) 781-6819; Fax: (612) 781-0109; [email protected]