Small Business Certification Worksheets

Corporate Point of Contact
Primary POC Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
US Phone
US Fax
Non US Phone
Non US Fax

Alternate POC Name
First Last
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
US Phone
US Fax
Non US Phone
Non US Fax

Non Federal Government Certifications:
Include state certifications or industry-related competence certifications (ie..State Certified Native American, MS Certified Systems Engineer, ColdFusion Certified Developer, Cisco Certified Internetwork Expert, RN, CPA, Licensed General Contractor, Electrician, HVAC). Only fill out as many as desired.
Name Title Certifications
Name Title Certifications
Name Title Certifications
Name Title Certifications
Name Title Certifications
Name Title Certifications
CAPABILITIES STATEMENT*
Please provide 3-5 sentences explaining your organization’s core competencies and differentiators. This will be a summary that potential contractors see.
FEMA
Disaster Relief Assistance: Please list special Equipment, materials, skills, and geographic area (if applicable)
Construction Bonding Level – Aggregate:
Construction Bonding Level – Per Contract:
Service Bonding Level – Aggregate:
Service Bonding Level – Per Contract:

GOVERNMENT PAST PERFORMANCE
Has your organization held contracts with any local, state, or federal government entities/departments? (Only fill out as many as desired)
Government Entity:
Project Name:
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Value:
Contact Name
First Last
Contact Phone
Government Entity:
Project Name:
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Value:
Contact Name
First Last
Contact Phone
Government Entity:
Project Name:
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Value:
Contact Name
First Last
Contact Phone

Corporate Point of Contact