Connellsville, Pennsylvania

Connellsville Redevelopment Authority

Section 3


Certification for Business Concerns Form


CERTIFICATION FOR BUSINESS CONCERNS SEEKING SECTION 3 PREFERENCE IN CONTRACTING AND DEMONSTRATION OF CAPABILITY


Name of Business__________________________________

Address of Business_________________________________

_________________________________________________

Type of Business:  Corporation  Partnership

 Sole Proprietorship  Joint Venture 

Attached is the following documentation as evidence of status:

For Business claiming status as a Section 3 resident-owned enterprise:

 Copy of resident lease  Copy of receipt of public assistance

 Copy of evidence of participation  Other evidence in a public assistance program

For business entity as applicable:

 Copy of Articles of Incorporation  Certificate of Good Standing

 Assumed Business Name Certificate  Partnership Agreement

 List of owners/stockholders and % ownership of each

  Corporation Annual Report

  Latest Board minutes appointing officers

 Organization chart with names and titles

  Additional documentation and brief function statement

For business claiming Section 3 status by subcontracting 25 percent of the dollar awarded to qualified Section 3 business:

 List of subcontracted Section 3 business(es) and subcontract amount


For business claiming Section 3 status, claiming at least 30 percent of their workforce are currently Section 3 residents or were Section 3 eligible residents within 3 years of date of first employment with the business:

 List of all current full-time employees  List of employees claiming Section 3 status

 PHA/IHA Residential lease less than 3  Other evidence of Section 3 status less than 3 years from day of employment years from date of employment

Evidence of ability to perform successfully under the terms and conditions of the proposed contract:

 Current financial statement

 Statement of ability to comply with public policy

 List of owned equipment

 List of all contracts for the past two years



____________________________________(Corporate Seal)

Authorizing Name and Signature


Attested by:  _____________________________