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A Veteran? <br />A Minority?T <br />L_l f, <br />T <br />T <br />LI <br />ls your business owned by a person (or persons) who is (or are) (Check all that apply) <br />A Woman? <br />NOT certified.ARE Certified* <br />Yes, but we are Yes and weNo Certification Number <br />Section Three: Contractor Ownership Type (DSHS staff enter, as applicable, on ACD lntake Detail screen) <br />Section Four: Contractor Primary Contact Person (DSHS staff enter on ACD lntake Detail screen) <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 Siate's Office of Minority and Women-Owned Business Enterprises (OMWBE) <br />www.omwbe.wa.qov, or Department of Veterans' Affairs (DVA) <br />ls your business a certified Disadvantaged Business Entity? I ttto I Yes, Certification No. <br />Does your business qualify as a Microbusiness, Minibusiness, or Small Business under RCW 39 26.010? X No X Ves <br />Primary contact person is a(n): <br />I Owner n Officer or Board Member D Partner I Staf Member I Elected Official <br />I Otfrer (please identify) <br />ls the primary contact person authorized to sign contracts?lYes nruo <br />PRIMARY CONTACT NAME AND JOB TITLE <br />Billing address <br />Facility address clTY' STATE' AND ZIP coDE <br />Mailing address <br />(DSHS staff enter as applicable on ACD) <br />PRIMARY CONTACT EMAIL ADDRESS CELLULAR PHONE NUMBER (INCLUDE AREA CODE) <br />() <br />COUNTY WHERE PRIMARY ADDRESS IS (FOR OUT.OF-STATE CONTRACTORS) <br />EMAIL ADDRESS <br />i COUNTY WHERE PRIMARY ADDRFSS lS (FOR OUT-OF-STATE CONTRACTORS) <br />FAX NUMBER (INCLUDE AREA CODE) <br />() <br />ADDRESS <br />DESCRIPTION <br />PHONE NUMBER (INCLUDE AREA CODE) <br />() <br />FAX NUMBER (INCLUDE AREA CODE) <br />() <br />ADDITIONAL ADDRESS (NUMBER, STREET, AND APARTMENT OR SUITE NUMBER) <br />TlI <br />ADDRESS ADDITIONALADDRESS(NUMBER,STREET,ANDAPARTMENTORSUITENUMBER) <br />DESCRIPTION <br />I eitting address <br />I Facility address <br />I wtaiting address <br />CITY, STATE, AND ZIP CODE <br />( <br />PHONE NUMBER (INCLUDE AREA CODE) <br />) <br />FAX NUMBER (INCLUDE AREA CODE) <br />() <br />NEW CONTRACTOR INTAKE <br />DSHS 27-043 (REV. 04i2023) <br />ADDITIONAL CONTRACTOR ADDRESSES: IF YOU HAVE MORE THAN TWO ADDITIONAL ADDRESSES, YOU MAY ATTACH <br />A LISTING OF ADDITIONAL ADDRFSSES. <br />1 <br />Section Five: Additional lnformation (DSHS staff enter on lntake Detail - Sub lnformation Summary screens) <br />PHONE NUMBER (INCLUDE AREA CODE) <br />() <br />EMAIL ADDRESS <br />Page 3 of 4