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