HUBZone Certification (Historically Under Utilized Business Zone) Step 1 of 3 33% Section A - Qualified HubZonePrincipal Office Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Other Address (Mailing) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is the Principal office location located in a qualified census tract? Yes No Is the Principal office location located within the external boundary of a Federally recognized Indian reservation? Yes No Is the Principal office location located within the BRAC Former Military Base? Yes No Is the Principal office location located in a re-designated area? Yes No Section B - General InformationLegal Business Name DUNS Number CAGE Code Tax Identification Number or Employee Identification Number Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Initial Last Contact Phone*Contact FaxContact Email* Structure of Business Corporations Sole Proprietors Partnerships Limited Liability Company Business TypeFor ProfitNon ProfitPrimary NAICS Code (this should be a 6 digit number) Business Start Date MM slash DD slash YYYY Fiscal Year End Date MM slash DD slash YYYY State Business was Established Is your company owned in whole or part by one or more Indian Tribal Governments, or owned in whole or part by a corporation that is wholly owned by one or more Indian Tribal Governments? Yes No Is your company wholly owned by a Community Development Corporation (CDC) or owned in part by one or more CDCs? Yes No Is your company an Alaskan Native Corporation (ANC) owned and controlled by Natives (determined pursuant to section 29(e)(1) of the ANCSA); or a direct or indirect subsidiary corporation, joint venture, or partnership of an ANC qualifying pursuant to section 29(e)(1) of ANCSA, if that subsidiary, joint venture, or partnership is owned and controlled by Natives (determined pursuant section 29(e)(2)) of the ANCSA) Yes No Is your company Applying for HUBZone Certification a small agricultural cooperative organized or incorporated in the United States, wholly owned by one or more small agricultural cooperatives organized or incorporated in the United States or owned in part by one or more small agricultural cooperatives organized or incorporated in the United States? Yes No Number of individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, at time of application who work at the location? Number of individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, at time of application who work at off-site, contract specific job sites Number of individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, at time of application Number of individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, who reside in a HUBZone at time of application Average number of employees on your company's payroll during the last 12 calendar months Average annual revenue for the applicant company over its last three Fiscal Years Has the applicant ever been debarred, suspended, voluntarily excluded or otherwise rendered ineligible by any department or agency of the Federal Government? Yes No Section D - AffiliationDoes the applicant concern own an interest in any other business? Yes No Does any other business own an interest in the applicant concern? Yes No Section E - Financial InformationLast fiscal year MM slash DD slash YYYY Last tax return filing date* MM slash DD slash YYYY Total Receipts ($)Net profit ($)*Current Assets ($)Current Liabilities ($)*Fixed Assets ($)*Long-Term Liabilities ($)*Other Assets ($)*If for any reason, you are not able to supply the complete financial information, please explain whySection F - HubZone Employment-Individual Employment DataThe applicant company has researched the resident status of its employees and has determined that at least 35% of all individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, are HUBZone residents?* Yes No The applicant company calculated the percentage of HUBZone residents utilizing current employment records as of the date of this application and will ensure that these records and all other pertinent information are maintained to document that at least 35% of all individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, are HUBZone residents* Yes No * 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 Name of the organization*
Call the USBRI SAM REGISTRATION HELP DESK: 1-888-646-9998
Call the USBRI SAM REGISTRATION HELP DESK: 1-888-646-9998