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Section 3 Self Certification
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Exhibitor Registration Self Certification Form 06-04
Section 3 Self Certification Form
Are you self certifying as a business or individual?
Please select
Business
Individual
Other
First Name
Last Name
Address
Enter City, Sate, Zip
Email
Do you live in public housing or section 8 community?
Please select
Yes
No
What current programs do you receive?
TANF
SNAP
Medicaid
Disability/SSI/SSD
Other
Other
What is your annual income?
Please select
<$25k
$25-$50k
$50-$75k
$75-$100k
$100k+
Other
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?
Please select
Professional Services
Construction related
Administration
Other
Other
Choose Your Industry
-- Please Select --
Construction
Professional Services
Administrative Management
Other
Other
Is your business searching for new contracts/opportunities?
Please select
Yes
No
Other
Social Media Handles (Names)
Facebook
Twitter
LinkedIn
Other
Are you currently enrolled in the FSS Program?
Please select
Yes
No
On Waiting List
What is your age?
Please select
17 or younger
18-20
21-29
30-39
40-49
50-59
60 or older
What is the highest level of school you have completed or the highest degree you have received?
Please select
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Which of the following categories best describes your employment status?
Please select
Employed, working 40 or more hours per week
Employed, working 1-39 hours per week
Not employed, looking for work
Not employed, NOT looking for work
Retired
Disabled, not able to work
List any barriers to employment and or education, if any:
Please select
Criminal Background
Child Care
Transportation
Mental Health Needs
Other
Other
How much total combined money did all members of your HOUSEHOLD earn last year?
Please select
$0 to $9,999
$10,000 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $174,999
$175,000 to $199,999
$200,000 and up
Prefer not to answer
Are you currently enrolled as a student?
Please select
Yes, full time in graduate school
Yes, part time in graduate school
Yes, full time at a four year undergraduate college/university
Yes, part time at a four year undergraduate college/university
Yes, full time at a two year undergraduate college/university
Yes, part time at a two year undergraduate college/university
Yes, at a high school or equivalent
No, I am not currently enrolled as a student
Choose a goal you would like to work towards:
Education (obtain GED, certification and or degree)
Entrepreneurship (start or grow a small business)
Equity (Purchase your first home)
Employment (increase my earning, get promoted or switch careers)
Other
Other
List CURRENT Skills, trades and or certifications that you possess or will possess soon:
Adminsitrative/ Office Support
Barber/Hair Stylist/Cosmetology License
Book-keeping/Accounting
Bus /Truck Driver
Carpentry
Certified Nurses Assistant (CNA)
Construction
Cooking/Catering Degree or License
CDL (Commercial Driver's License)
Data Entry
Drywall
Electrical
Graphic Artist
Home Health Aide
HVAC
Landscaping
Maintenance
Martial Artist
Masonry
Media Production
Medical Assistant
Military
Nursing
Painting
Plumber
Property Management
Real Estate
Retail
Security Officer
Sports/Recreation
Tattoo Artist
Teacher
Teacher's Aide
Uber
Video Broadcasting
Other
Other
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.
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