1.	Firm Name:

Street Address:

City, State and Zip Code:

Telephone:	Fax Number:

E-Mail Address:

2.	Firm Established: (Year)

3.	Type of Organization: (Check one)

Sole Proprietorship	Partnership	Corporation	Joint Venture

Other

4.	Principal (P) and Associates (A): (Check “P” or “A” for each) Attach additional sheets as required.

NAME

P

A

STATEMENT of QUALIFICATION Submitted by:

(Signature)	(Print Name)

(Title)

Date:

Please attach to this form any other information that is specifically related to the requirements of this project:

Project Name:

Project Number:

PRIVACY NOTIFICATION

The state of California Information Practices Act of 1977 requires the University to provide the following information to individuals who are asked to supply information about themselves:

The principal purpose for requesting the information on this form is for use in the selection process for Design Professionals commissioned by the University. University Policy authorizes maintenance of this information.

Furnishing all information requested on this form is mandatory - failure to provide such information will delay or may even prevent completion of the action for which the form is being filled out. Information furnished on this form will be used by the Office of Design & Construction Services and Physical Facilities, University of California at Santa Barbara in consideration of commissions to Design Professionals.

Individuals have the right to access to this record as it pertains to themselves.

The official responsible for maintaining the information contained on this form:

Contracting Office at Design & Construction Services and Physical Facilities

Building 439

University of California, Santa Barbara

Santa Barbara, California 93106-1030

For further assistance regarding this form please contact: Linda Playman (805) 893-2910

The principal purpose of requesting the following information is for statistical reporting purposes only.

Check the Business Categories that apply:

Small Business Enterprise (SBE) - an independently owned and operated concern certified, or certifiable, as small business by the Federal Small Business Administration (SBA). (Size standards by Standard Industrial Classification codes may be found in the Federal Acquisition Regulations, Section 19.102. The University may rely on written representation by the vendors regarding their status.)

Disadvantaged Business Enterprise (DBE) - a business concern which is at least fifty-one percent (51%) owned by one or more socially and economically disadvantaged individuals or, in the case of any publicly owned business, at least fifty-one percent (51%) of the stock of which is owned by such individuals and whose management and daily business operations are controlled by one or more of such individuals. Socially disadvantaged individuals are those who have been subjected to racial or ethnic prejudice or cultural bias because of their identity as members of a group without regard to their individual qualities. Economically disadvantaged individuals are those socially disadvantaged individuals whose ability to compete in the free private enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same business area who are not social disadvantaged. Business owners who certify that they are members of named groups (Black Americans, Hispanic Americans, Native Americans, Asian-Pacific Americans, Asian-Indian Americans) are to be considered socially and economically disadvantaged.

Women-Owned Business Enterprise (WBE) - a business that is at least fifty-one percent (51%) owned by a woman or women who also control and operate it. "Control" in this context means exercising the power to make policy decisions. "Operate" in this context means being actively involved in the day-to-day management.

Disabled Veteran Business Enterprise (DVBE) - a business that is at least fifty-one percent (51%) owned by one or more disabled veterans or, in the case of any publicly owned business, at least fifty-one percent (51%) of the stock of which is owned by such individuals and whose management and daily business operations are controlled by one or more of such individuals. A Disabled Veteran is a veteran of the military, naval, or air service of the United States with a service connected disability who is a resident of the State of California. To qualify as a veteran with a service connected disability, the person must be currently declared by the United States Veterans Administration to be ten percent (10%) or more disabled as a result of service in the

UNIVERSITY OF CALIFORNIA, SANTA BARBARA

DESIGN & CONSTRUCTION SERVICES and PHYSICAL FACILITIES

SANTA BARBARA, CALIFORNIA 93106-1030

STATEMENT OF QUALIFICATIONS

SOQ Form - RFQ Signature .doc	Page 1 of 3

SOQ-RFQ Sign/2005_05-12

Rev. 0

Statement of Qualifications

Anna Galanis

2005-05-17

KildareR

UC Santa Barbara