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Section Three: Contractor Ownership Type (DSHS staff enter, as applicable, on ACD Intake Detail screen) <br />Is your business owned by a person (or persons) who is (or are) (Check all that apply): <br />No <br />Yes; but we are Yes and we 1 Certification Number <br />NOT certified* ARE Certified* <br />A Woman? ❑ ❑ <br />El <br />A Minority? ❑ ❑ ❑ <br />A Veteran? ❑ ❑ ❑ <br />*Certified means either the business entity (or, when the business is a sole proprietorship, the individual) has received a <br />certification number from Washington State's Office of Minority and Women -Owned Business Enterprises (OMWBE) <br />www.omwbe.wa.gov, or Department of Veterans' Affairs (DVA). <br />Is your business a certified Disadvantaged Business Entity? ❑ No ❑ Yes, Certification No. <br />I Does your business qualify as a Microbusiness, Minibusiness, or Small Business under RCW 39.26.010? ❑ No ❑ Yes <br />Section Four: Contractor Primary Contact Person <br />(DSHS staff enter on ACD Intake Detail screen) <br />Primary contact person is a(n): <br />❑ Owner ❑ Officer or Board Member ❑ Partner ❑ Staff Member ❑ Elected Official <br />❑ Other (please identify) <br />Is the primary contact person authorized to sign contracts? <br />PRIMARY CONTACT NAME AND JOB TITLE <br />FAX NUMBER (INCLUDE AREA CODE) <br />(DSHS staff enter as applicable on ACD) <br />❑ Yes ❑ No <br />PHONE NUMBER (INCLUDE AREA CODE) <br />PRIMARY CONTACT EMAIL ADDRESS CELLULAR PHONE NUMBER (INCLUDE AREA CODE) <br />Section Five: Additional Information (DSHS staff enter on Intake Detail — Sub Information Summary screens) <br />1. ADDITIONAL CONTRACTOR ADDRESSES: IF YOU HAVE MORE THAN TWO ADDITIONAL ADDRESSES, YOU MAY ATTACH <br />A LISTING OF ADDITIONAL ADDRESSES. <br />ADDRESS ADDITIONAL ADDRESS (NUMBER, STREET, AND APARTMENT OR SUITE NUMBER) <br />DESCRIPTION <br />❑ Billing address <br />❑ Facility address <br />❑ Mailing address <br />CITY, STATE, AND ZIP CODE <br />PHONE NUMBER (INCLUDE AREA CODE) <br />FAX NUMBER (INCLUDE AREA CODE) <br />COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT-OF-STATE CONTRACTORS) <br />EMAIL ADDRESS <br />ADDRESS ADDITIONAL ADDRESS (NUMBER, STREET, AND APARTMENT OR SUITE NUMBER) <br />❑ Billing address _ <br />❑ Facility address CITY, STATE, AND ZIP CODE <br />❑ Mailing address <br />PHONE NUMBER (INCLUDE AREA CODE) <br />FAX NUMBER (INCLUDE AREA CODE) <br />COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT-OF-STATE CONTRACTORS) <br />EMAIL ADDRESS <br />NEW CONTRACTOR INTAKE Page 3 of 4 <br />DSHS 27-043 (REV. 04/2023) <br />