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Please select the project you are interested in. Click here for a PDF version of the form. Fax the completed application to 703-781-7701 attn: Small Business Office.

Fort Belvoir, Virginia	Quantico MCB, Virginia
Monterey Bay, California	Fort Irwin/Moffett/Parks Military Housing, California

Please complete the following:

Company Name		Years in Business
Company Street Address		P.O. Box or Suite Number
City	State	Zip Code
Telephone Number	Fax Number	Other Number
Contact Name	Contact Title	Email Address
Company Website

Please list all Trade(s), Product(s) and Services you are interested in. To review trade list, please review the project purchase schedule.

Limit 3 per company. Please list only those trades which your company “self-performs”.

Fort Belvoir

Purchase Schedule

Trade #1:
Trade #2:
Trade #3:

Quantico Marine Corps Base

Purchase Schedule

Trade #1:
Trade #2:
Trade #3:

Is your company bondable?
Yes No

Bonding capacity (in US $)

Identification and Certification
Disadvantaged, Women, Small, Disabled Veteran and Hubzone Small Business Enterprise Program

Clark Realty Builders, LLC is a General Contractor and fully supports legislation pertaining to the employment of Disadvantaged, Women, Small, Disabled Veteran and HubZone Small Business Enterprises in construction.

Under the requirements of The Small Business Act, we are required to know the classification of your company. Each classification is listed below with a brief explanation. Please check the appropriate box which describes your company and return this form to us.

Yes No	Small Disadvantaged Business Concern (A1) - A Small Business Concern as defined under Item 3 below and which is owned and controlled by socially and economically disadvantaged individuals. The term “Small Business Concern owned and controlled by socially and economically disadvantaged individuals” means a Small Business Concern that is at least 51 percent unconditionally owned by one or more socially and economically disadvantaged individuals; or, in the case of any publicly owned business, at least 51 percent of the stock of which is unconditionally owned by one or more socially or economically disadvantaged individuals; and whose management and daily business operations are controlled by one or more such individuals. Subcontractor/Supplier shall presume that socially and economically disadvantaged individuals include Black Americans, Hispanic Americans, Native Americans (such as American Indians, Eskimos, Aluets, and Native Hawaiians), and other minorities or any other individuals found to be disadvantaged by the Small Business Administration pursuant to Section 8(a) of the Small Business Act.

Yes No	Women Small Business Concern (B1) - Same as Small Business Concern, Item 3 below, except a women owned and controlled business whose management and daily business operations are controlled by one or more women.

Yes No	Small Business Concern (C1) - A firm is generally considered such if its average annual receipts for its preceding 3 fiscal years do not exceed $12 million for Special Trades Contractors and $28.5 million for Heavy Construction, pursuant to the governing regulations of the Small Business Administration (13 CFR Part 121 and FAR Part 19). (see website www.sba.gov/size)

Yes No	Disabled Veteran Business Enterprise (E1) - It is a sole proprietorship or partnership at least 51 percent owned by one or more disabled veterans. (see attachment for definition)

Yes No	Hubzone Small Business Concern (H1) - A Small Business Concern that appears on the List of Qualified HubZone Small Business Concerns maintained by the Small Business Administration.

The undersigned hereby certifies that he is authorized to execute this document on behalf of the said firm that and the statements contained herein are true.

Firm Name	Telephone Number
Address	Fax Number
City, State & Zip	Email Address
Signature (Please print Name and Title)	Date: 01/06/2009

Clarifications and References

Certification Date (s)	Certifying Agency
Certification Number
Geographical Area	Union / Non-Union
Bonding Agency
Years in Business	Number of Permanent Employees

List 5 recent jobs completed:

1.	Name of Job:
	Owner/Contractor:
	Telephone Number:
	Contract Amount:

2.	Name of Job:
	Owner/Contractor:
	Telephone Number:
	Contract Amount:

3.	Name of Job:
	Owner/Contractor:
	Telephone Number:
	Contract Amount:

4.	Name of Job:
	Owner/Contractor:
	Telephone Number:
	Contract Amount:

5.	Name of Job:
	Owner/Contractor:
	Telephone Number:
	Contract Amount:

Thank you for taking the time to complete this application. Upon submission, a copy of this application will be sent to your contact email address.

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