2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387) | WisVets.com
Wis. Stats. Chapter 45 VETERAN–OWNED BUSINESS REQUEST FOR CERTIFICATION

Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].
This Department does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or provision of services. Title II of the American Disabilities Act signed January 26, 1992.

To apply for certification as a "veteran-owned business" complete the following and return to the Veterans Benefits Resource Center, Attn: VBRC, Wisconsin Department of Veterans Affairs, 2135 Rimrock Road, P.O. Box 7843, Madison, WI 537077843. All certified applicants will receive a Wisconsin “Veteran Owned Business” logo.

Veteran Owner(s)	Title
Legal Business Name
Contact Person	Telephone
E-mail Address	Website Address
Mailing Address
City	State	Zip Code
Federal Employer Identification Number Social Security Number
– OR – –
Signature	Date
Print Name	Title

Please check all that apply:

☐ The above named business is a "small business," having had less than $1,500,000.00 in gross annual sales in the most recent calendar or fiscal year as required by s.16.75(4)(c).

☐ The above named business is at least 51% owned by one or more veterans, as defined in s.45.01(12). Attach a copy of the form DD 214 for each veteran owner. Attach documentation sufficient to establish the ownership of at least 51% of the business by a veteran owner or owners. Such documentation may include, but is not limited to the following: IRS Form 1040 Schedule C (Profit or Loss From Business), IRS Form 1065 Schedule K-1 (Partner’s Share of Income, Deductions, Credits, etc.), Stock Certificates, Corporate by laws, Member Control Agreement, Operating Agreement, Shareholders’ Agreement, Partnership Agreement, IRS Form SS-4 that assigns FEIN (Federal Employer Identification Number).

NOTE:	Bolded items That are Checked above are required and must be returned with request in order to be considered for certification.

For Department Use Only
Certification Number	State Agency Copies
Certification Approved By	Date