Certification Acknowledgement Form Your Name* Company Name* Choose a certification*System for Award Management (SAM)Woman Owned Small Business Certifications (WOSB)Economically Disadvantaged Woman Owned Small Business (EDWOSB)Veteran Owned Small Business Certifications (VOSB/SDVOSB)HUBZone Certification8(a) ProgramState CertificationUnited States Business Registration Inc (888) 646-9998 Toll-Free (888) 255-4963 Fax info@usbri.us 1310 Heather Ridge Blvd Dunedin, FL 34698 www.usbri.us Small Business Certification Qualification Interview Acknowledgement & Agreement As a primary officer/owner/authorized legal representative of . I confirm that I have completed the qualification interview with the Director of Registrations for the Certification. All information provided to the Director whether oral or in writing was truthful and accurate as of the date of the interview. I understand that I meet the qualifications for applying for the Certification. I, , have access to all the pertinent documents mentioned within the qualification interview required to apply for the stated certification. I meet the Small Business Administration's size standards for the applicable NAICS codes, as gone over within the interview. My business organization is properly structured and legally registered within the state I operate within. I fully understand that if any documents that are submitted to either United States Business Registration or the Small Business Certification Approval Agency contradict the information provided to the Director of Registrations within the qualification interview, may result in the denial or delay of my Certification application. If this occurs United States Business Registration, it's officers, contractors, employees, etc. cannot be held responsible for the denial of the application for the certification submitted. If this occurs, our Executive Director will look at your certification submission for any possibilities of appealing and resubmitting for approval.* As an officer, director, owner, legal representative or authorized representative of the organization stated throughout this document, I attest that all information provided is true and correct to the best of my knowledge. Type Your Name* Date* MM slash DD slash YYYY