EDWOSB/WBE (Economically Disadvantaged Woman Owned Small Business) Contact Name* Contact Phone*Contact Email Address* Company Name Company Type*S CorpC CorpLLCLTDSole ProprietorshipDUNs* EIN/TIN* Qualifying NAICS Code* Certification Type WBE WOSB Both 1. WBE Applicants: Is your company at least 51% owned and controlled by one or more women who are U.S. Citizens or Permanent Legal Residents? Yes No 2. WBE Applicants: Is your business formation and principal place of business located in the U.S. or its territories? Yes No 3. WBE Applicants: Is the company's management and daily operation controlled by a woman with industry experience? Yes No 4. WBE Applicants: Has you company been denied WBENC Certification within the last 6 months? NOTE: If you are unsure, please consult the female owner and/or the Regional Partner Organization (RPO) to confirm. Yes No 5. WBE Applicants: Were your firm's Annual Gross Receipts for the last year $500 Million or more? Yes No 6. WBE Applicants: Do you agree to pay the nonrefundable application processing fee? Yes No 7. WOSB Applicants: Is the majority woman owner(s) a U.S. citizen? (Please select N/A if you do not want to be considered for WOSB.) Yes No Not Applicable 8. WOSB Applicants: Does the Woman holding the highest defined position work in the business at least 30 hours per week during normal hours of operation? (Please select N/A if you do not want to be considered for WOSB.) Yes No Not Applicable 9. Do women make up a majority of the Board of Directors OR have a majority of the Board votes through weighted voting? OR Do the women who up 51% of the voting power sit on the Board AND have enough voting power to overcome any supermajority requirement? (Please select N/A if you do not want to be considered for WOSB.) Yes No Not Applicable 10. Can you prove that your personal net worth is less than $750,000, including ownership and equity in your per Yes No 11. Can you prove your status as economically disadvantaged for the past three years? Yes No 12. The average Adjusted Gross Income of the economically disadvantaged woman over the past three years doesn't exceed $350,000. True False 13. The average AGI over the past 3 years is over $350k, but you can prove this was unusual and not likely to reoccur. True False 14. The fair market values of all your assets doesn't exceed $6 million. True False Do you work as a W-2 employee with any other organization(s)? Yes No If yes, please explain. Be sure to include the average number of hours worked per week* 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. Signature* Title* Date* MM slash DD slash YYYY Organization Name*
Call the USBRI SAM REGISTRATION HELP DESK: 1-888-646-9998
Call the USBRI SAM REGISTRATION HELP DESK: 1-888-646-9998