Business Enterprise Questionnaire - NY Question Title * 1. Company Name Question Title * 2. DBA (If Applicable) Question Title * 3. Contact Name Question Title * 4. Street/Suite Question Title * 5. City Question Title * 6. State Question Title * 7. Zip Code Question Title * 8. Phone Number (XXX-XXX-XXXX) Question Title * 9. Email Address Question Title * 10. Website Question Title * 11. Certification Status MBE WBE M/WBE NOT CERTIFIED Question Title * 12. Certifying Entity NYS ESD NYC SBS PANY/NJ SCA NMSDC WBENC NOT CERTIFIED Other (please specify) Question Title * 13. Certifying Entity - Disadvantaged Business Enterprise (DBE) NYS UCP NJ UCP NOT CERTIFIED Other (please specify) Question Title * 14. Certifying Entity - Service Disabled Veteran (SDVOB, SDVBE) NYS OGS SAM.GOV NOT CERTIFIED Other (please specify) Question Title * 15. Certifying Entity - Veteran Business Enterprise (VBE) SAM.GOV NOT CERTIFIED Other (please specify) Question Title * 16. Certifying Entity - LGBTQ+ NGLCC NOT CERTIFIED Other (please specify) Question Title * 17. Certifying Entity - Local Business Enterprise (LBE) Entity 1 Entity 2 Entity 3 Question Title * 18. Certifying Entity - Small Business Enterprise (SBE) Entity 1 Entity 2 Entity 3 Question Title * 19. Certifying Entity - Section 3 Business Concern (S3BC) Entity 1 Entity 2 Entity 3 Question Title * 20. Section 3 Resident Yes No Question Title * 21. Name of person with largest % ownership Question Title * 22. Gender of person with largest % ownership F M X Question Title * 23. Ethnicity of person with largest % ownership White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Prefer Not to Disclose Question Title * 24. Business Type Architectural/Engineering Services Other Services (Including consultants) Trade Partner/Subcontractor Supplier Broker/Manufacturer's Rep Manufacturer/Fabricator Trucker Other (please specify) Question Title * 25. License Types (i.e. Electrical, Plumbing etc.) License 1 License 2 License 3 Question Title * 26. Professional Services (i.e. Architect, Engineer, Survey etc.) Service 1 Service 2 Service 3 Specialty Question Title * 27. Service Type (i.e. Security, Janitorial, Pest Control etc.) Type 1 Type 2 Type 3 Question Title * 28. Supplier Type (i.e. Drywall, Tools, MRO etc. ) Type 1 Type 2 Type 3 Question Title * 29. Industry Experience Affordable Housing Commercial Education Health Care Heavy Civil/Highway Life Sciences Mixed Use Residential Sports Facilities Transportation Other (please specify) Question Title * 30. NAICS Codes NAICS Code 1 NAICS Code 2 NAICS Code 3 NAICS Code 4 Question Title * 31. NIGP Codes NIGP Code 1 NIGP Code 2 NIGP Code 3 NIGP Code 4 Question Title * 32. Union Affiliation Yes No Question Title * 33. Union Local (i.e. 638) Local # Local # Local # Question Title * 34. Trade Type (i.e. GC, Carpentry, Electrician etc) Trade 1 Trade 2 Trade 3 Trade 4 Question Title * 35. Number of full time employees Question Title * 36. Number of part time employees Question Title * 37. % of work self performed (i.e. 25%, 50%, 75%, 100%) Question Title * 38. Annual Revenue ($X,XXX,XXX) Question Title * 39. Largest Contract ($X,XXX,XXX) Question Title * 40. Average Contract ($X,XXX,XXX) Question Title * 41. Total Insurance Limit Question Title * 42. Total Bonding Capacity Question Title * 43. Experience Modification Rating (i.e. X.XXX) Question Title * 44. Reference 1 Company Name Contact Name Email Address Phone Number Project Name Project Scope Your Contract Value ($) % of Work Self-Performed Question Title * 45. Reference 2 Company Name Contact Name Email Address Phone Number Project Name Project Scope Your Contract Value ($) % of Work Self-Performed Question Title * 46. Reference 3 Company Name Contact Name Email Address Phone Number Project Name Project Scope Your Contract Value ($) % of Work Self-Performed Question Title * 47. Judgements against your firm in the last 5 years Yes No If yes, please explain Question Title * 48. Failure to complete a project in the last 5 years Yes No If yes, please explain Question Title * 49. Prevailing wage violations in the last 5 years Yes No If yes, please explain Question Title * 50. Certification Denied or Revoked in the last 5 years? Yes No If yes, please explain Question Title * 51. Is it ok to share your information with other firms/agencies for the purpose of identifying potential opportunities? Yes No Done