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SECTION 3 BUSINESS SELF-CERTIFICATION
General Information:
I, the undersigned being duly sworn, on oath, represents,
warrants, certifies, deposes and says, under penalty of law, as follows:
1. Company Name:
2. Company Address: City State Zip
3. Business Telephone: Cellular telephone:
Fax: Email address:
4. Type of Business (examples: construction, electrician, catering, accounting, landscapes, etc.).
5. Contractors License: _____—Class “A” Class “B” Class “C”
6. Certifications: —___ SWaM ____ DBE Other
Please select "Yes" or "No". If you answer "YES" to one or more of the following questions, you may
designate your company as a Section 3 Business Enterprise.
1. 51% or more of the business is owned by a Section 3 resident; or
YES NO
2, 30% or more of the company’s full-time employees are Section 3 residents, or were Section 3 residents within the
past three years: or
YES NO
3. The company can provide evidence, as required, of a commitment to subcontract 25% or more of all
subcontract dollars to a certified and qualified Section 3 business enterprises.
YES NO
| declare and affirm under penalty of prosecution for perjury that the statements made herein are true and
accurate to the best of my knowledge. | understand that falsifying information and incomplete statements may
be cause to disqualify this certification.
Signature of Business Owner or Authorized Representative Date
Signature of Business Owner or Authorized Representative Date
Notary Public Jurist: City/County of in the Commonwealth of Virginia
The foregaing instrument was subscribed and sworn before me this. day of 20. by:
Notary (Please Print Name) Notary Signature
Marshall Courts Phase VI Demolition
LFB #MCP7D-09-24
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