Contractor Profile Form (Page 3 of 4) in pdf

PRIVACY NOTIFICATIONS

The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University of California to provide the

following information to individuals who are asked to supply information about themselves:

Failure to provide all requested information may delay or prevent evaluation of your firm’s ability to do business with

the University.

I hereby certify under penalty of perjury under the laws of the State of California that I have read this application and know the

contents thereof, and that the business category and ethnicity indicated above reflect the true and correct status of the business in

accordance with Federal Small Business Administration criteria and Federal Acquisition Regulations, FAR 19, pertaining to small,

disadvantaged, woman-owned, and disabled veteran-owned business enterprises. I understand that falsely certifying the status of this

business, obstructing, impeding, or otherwise inhibiting any University of California official who is attempting to verify the information

on this form may result in suspension from participation in University of California business contracts for a period up to five years and

the imposition of any civil penalties allowed by law. In addition, I understand that this business must notify the University of California

in writing 30 days in advance of any changes in size, ownership, control, or operation which may affect this business’s continued

eligibility as an SBE, DBE, WBE, DVBE, SDBE, SWBE or SDVBE.

Note: If you submit this profile form electronically, your submission of this form will be considered as to represent

your signature and you may be asked to sign a hard copy at a later date.

NAME OF BUSINESS:

NAME:

TITLE:

SIGNATURE:

DATE:

DEFINITIONS

LARGE BUSINESS ENTERPRISE (LBE): A business whose AVERAGE GROSS RECEIPTS, taken for the last 3 fiscal years (total

revenue compiled over the 3-year period divided by 3), EXCEED $2,500,000 PER YEAR.

SMALL BUSINESS ENTERPRISE (SBE): A business whose AVERAGE GROSS RECEIPTS, taken for the last 3 fiscal years (total

revenue compiled over the 3-year period divided by 3), DO NOT EXCEED $2,500,000 PER YEAR.

DISADVANTAGED BUSINESS ENTERPRISE (DBE): A business which is at least 51% owned by one or more socially and

economically disadvantaged individuals, or, in the case of a publicly owned business, a business concern for which at least 51% of the

stock is owned by one or more socially and economically disadvantaged individuals and whose management and daily business

operations are controlled by one or more such individuals. Socially disadvantaged individuals are those who have been subjected to

racial or ethnic prejudice or cultural bias because of their identity as members of a group without regard to their individual qualities.

Economically disadvantaged individuals are those socially disadvantaged individuals whose ability to compete in the free private

enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same business

area who are not socially disadvantaged. Business owners who certify that they are members of named groups (Asian/Indian

Americans, Asian/Pacific Americans, Black/African Americans, Hispanic Americans, Native Americans) are to be

considered socially and economically disadvantaged.

WOMAN-OWNED BUSINESS ENTERPRISE (WBE): A business that is at least 51% owned by a woman or women who also control

and operate it. “Control” in this context means exercising the power to make policy decisions. “Operate” in this context means being

actively involved in the day-to-day management.

DISABLED VETERAN BUSINESS ENTERPRISE (DVBE): A business that is at least 51% owned by one or more disabled veterans,

or, in the case of a publicly owned business, a business concern for which at least 51% of the stock is owned by one or more disabled

veterans and whose management and daily business operations are controlled by one or more such individuals. A Disabled Veteran, in

this context, is a veteran of the military, naval, or air service of the United States with a service-connected disability residing in the

State of California. To qualify as a veteran with a service-connected disability, the person must be currently declared by the United

States Veterans Administration to be 10% or more disabled as a result of service in the armed forces.

INSURANCE REQUIREMENTS

Insurance company must complete University’s Certificate of Insurance form. If Contractor’s insurance company refuses to

use the University’s form, it must provide a Certificate of Insurance (and endorsements if needed) evidencing compliance

including University’s Certificate of Insurance form Special Provisions 1 – 3.

For a copy of the University of California Insurance Form see:

UCSB Contractor Profile Form

Rev. 2/19/15

Printed 08/19/15

Contractor Profile Form Page 3

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