Exhibitor Registration Self Certification Form 06-04

Section 3 Self Certification Form

Are you self certifying as a business or individual?

First Name

Last Name

Address

Enter City, Sate, Zip

Do you live in public housing or section 8 community?

What current programs do you receive?

What is your annual income?

Business Name

Business Street Address

Business City

State

Zip

Business Telephone Number

Business Website Address

Business Point of Contact

Business Email

Contact Phone Number

Number of Employees

NAICS

Year Business Established

What kind of contract would be best suited for your company?

Choose Your Industry

Is your business searching for new contracts/opportunities?

Social Media Handles (Names)

Facebook

Twitter

Other

Are you currently enrolled in the FSS Program?

What is your age?

What is the highest level of school you have completed or the highest degree you have received?

Which of the following categories best describes your employment status?

List any barriers to employment and or education, if any:

How much total combined money did all members of your HOUSEHOLD earn last year?

Are you currently enrolled as a student?

Choose a goal you would like to work towards:

List CURRENT Skills, trades and or certifications that you possess or will possess soon:

I agree that the information in this form is true and exact to the best of my knowledge and that my income is considered Low or Very-Low as per the definition of very low income as defined in Section 3(b)(2) of the 1937 Act, as established at HUD Income limits.

I agree that the information in this form is true and exact to the best of my knowledge. I also certify that my business is considered a Section 3 Business Concern because it is at least 51 percent owned and controlled by low- or very low-income persons; or Over 75 percent of the labor hours performed for the business over the prior three-month period is performed by Section 3 workers; or It is a business at least 51 percent owned and controlled by current public housing residents or residents who currently reside in housing assisted by Section 8.