LIVE: Michels: Supplier Diversity

Company Information
Legal Company Name*
DBA/AKA Name
Contact Name*
Phone*
Please enter a valid phone number.
Email*
example@example.com
Physical Address*
City*
State*
Zip*
Is the mailing address the same as the physical address?

YesNo
Mailing Address
City
State
Zip
Website
Owner's First Name
Owner's Last Name
Owner's Email
Federal Tax ID Number*
D&B Number
Parent Company Affiliation
Annual Revenue*
Number of Employees*
Primary NAICS Codes
Additional NAICS Codes
Are you bonded?*

YesNoN/A
What is your project capacity?*
What is your aggregate?
How long have you been in a relationship with your surety?*
Upload a Good Guy Letter (optional)

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Are you affiliated with any unions?*

YesNo
Please list the names and locations of the union(s) you are affiliated with.*
Geographic Coverage

WestMidwestNortheastSouthwestSoutheastOther
Diverse Business Classification

Ability One Program (JWOD)Alaska and Native Owned Business (ANC)Disability-Owned Business Enterprise (DOBE)Disabled Veteran Business Enterprise (DVBE)Disadvantaged Business Enterprise (DBE)Economically Disadvantaged Women Owned Small Business (EDWOSB)Historically Underutilized Business Zone (Hub Zone)Indigenous Owned Business (Tribal Card)LGBT Business Enterprise (LGBT)Minority Business Enterprise (MBE)Minority/Women-Owned Business Enterprise (MWBE)SBA 8A Certified Business (SBA)Service-Disabled Veteran-Owned Business (SDVOB)Service-Disabled Veteran-Owned Small Business (SDVOSB)Small Business Enterprise (SBE)Small Disadvantaged Business (SDB)Veteran Business Enterprise (VBE)Veteran Owned Business (VOB)Veteran-Owned Small Business (VOSB)Woman-Owned Small Business (WOSB)Women Business Enterprise (WBE)
Certified by an NMSDC Affiliated Council? If yes, enter your Certificate Number and Expiration Date.
Upload NMSDC Affiliated Council Certificate*

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Certified by the WBENC? If yes, enter your Certificate Number and Expiration Date.
Upload WBENC Certificate*

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If you are certified by another agency or are indigenous and/or tribally owned, enter the name of each agency and/or tribal affiliation and the corresponding certificate number(s) and expiration date(s) here. (One per line).
Upload Other Certificates and/or Tribal Cards*

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SBA Contracting Assistance Programs
A small business is a business that is classified as small under the guidelines set forth by the SBA. Business size is dependent on a company's NAICS code and number of employees or annual sales. For more information, please refer to www.sba.gov/size.
Unique Entity ID
Are you certified by the SBA? Please check all that apply.

8AWOSBSDVOSBHUBzone
Upload SBA Certificate*

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Have you been involved in a Mentor Protégé (MPP) relationship?*

YesNo
Have you been involved in a Joint Venture (JV) relationship?*

YesNo
Have you worked with Michels previously?*

YesNo
Please list the Project(s), Bids, and Michels point of contact(s).*
Ability to prime federal contracts?*

YesNo
Please list past projects.*
Is your entity or any of its principals currently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any federal agency?*

YesNo
Has your company failed to complete a project?*

YesNo
Please explain why.*
Has your company received any OSHA citations in the last three years?*

YesNo
Please explain the citations.*
Is there anything else you'd like us to know?
Acknowledgement

The undersigned declares the above statements are true and correct.

IMPORTANT NOTICE: Under 15 U.S.C. 645(d), any person who misrepresents a firm's size or disadvantaged status in order to obtain a federal contract or subcontract 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.
Owner Signature*

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Title*
Date*

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Company Name*
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Company Information

SBA Contracting Assistance Programs

Acknowledgement