HUBZone Certification (Historically Under Utilized Business Zone) Step 1 of 3 33% Section A - Qualified HubZonePrincipal Office Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other Address (Mailing) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the Principal office location located in a qualified census tract?YesNoIs the Principal office location located within the external boundary of a Federally recognized Indian reservation?YesNoIs the Principal office location located within the BRAC Former Military Base?YesNoIs the Principal office location located in a re-designated area?YesNo Section B - General InformationLegal Business NameDUNS NumberCAGE CodeTax Identification Number or Employee Identification NumberName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Initial Last Contact PhoneContact FaxContact Email Structure of BusinessCorporationsSole ProprietorsPartnershipsLimited Liability CompanyBusiness TypeFor ProfitNon ProfitPrimary NAICS Code (this should be a 6 digit number)Business Start Date Fiscal Year End Date State Business was EstablishedIs 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?YesNoIs your company wholly owned by a Community Development Corporation (CDC) or owned in part by one or more CDCs?YesNoIs 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)YesNoIs 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?YesNoNumber 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 sitesNumber 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 applicationNumber 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 applicationAverage number of employees on your company's payroll during the last 12 calendar monthsAverage annual revenue for the applicant company over its last three Fiscal YearsHas the applicant ever been debarred, suspended, voluntarily excluded or otherwise rendered ineligible by any department or agency of the Federal Government?YesNo Section D - AffiliationDoes the applicant concern own an interest in any other business?YesNoDoes any other business own an interest in the applicant concern?YesNoSection E - Financial InformationLast fiscal year Last tax return filing date* 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?*YesNoThe 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*YesNo* 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* 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