T H E N Ava J O N at I O N

T H E N AVA J O N AT I O N

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

Welcome to the Navajo Nation Business Regulatory, Business Source Listing Application.

All documents for application are located in this document. Please read through the application thoroughly and follow the instructions for filling out each page.

To submit applications by email: [email protected]

To mail applications: Business Regulatory, Division of Economic Development PO Box 663 Window Rock, Arizona 86515

To drop off applications: Karigan Professional Building 100 Taylor Road St. Michaels, Arizona 86511

Questions? [email protected] 928.871.6544

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

BUSINESS REQUIREMENTS FOR CERTIFICATION

APPLICATION TYPE: □ Application A: Construction Contracting □ General Contractor Lic.#______Class:______□ Special Trades Lic.#______□ Subcontractor □ Application B: Professional □ Supplier □ DOCUMENTATION:Professional Services □ Proof of EIN or Social Security Number □ List of Past Projects/Work □ Duties & Responsibilities of Owner(s) or Highest Echelon □ Certificate of Indian Blood

PROCUREMENT ITEMS: YES NO Are you a Veteran? Do you have a current Navajo Nation Business Site Lease? Do you have an outstanding loan with the Navajo Nation? Have you filed your Office of Navajo Tax Commission Form 100? (To complete form, visit: www.tax.navajo-nsn.gov)

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

NAVAJO BUSINESS OPPORTUNITY ACT PRIORITY CERTIFICATION

PROFESSIONAL SERVICES BUSINESS REGULATORY DEPARTMENT DISCLAIMER

The purpose of the Navajo Business Opportunity Act priority certification is to determine if an entity is eligible for priority preference and to allow those certified entities priority preference when submitting bids and/or proposals in the procurement of services and/or goods. Priority certification does not guarantee that the certified entities are deemed responsive and/or responsible to provide the particular services and/or goods required of/by the contract letting entity. Priority certification of an entity is limited to the activities listed as goods and/or services in section G.9.

The Business Regulatory Department, Navajo Nation does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of any information disclosed in this application.

______By initialing in the space provided, I understand and accept the Business Regulatory Department’s Disclaimer Statement.

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

NAVAJO BUSINESS OPPORTUNITY ACT PRIORITY CERTIFICATION FOR PROFESSIONAL SERVICES

NOTE: 1. Application must be typewritten or printed legibly. 2. Application and all attachments must be originals. 3. Any Incomplete application will be returned.

PART A. GENERAL INFORMATION:

Today’s Date:

Legal Business Name: Legal Name of Business Mailing Address: Street or P.O. Box

City State Zip Principal Place Of Business: Physical Address

City State Zip

Contact Person: (Owner(S) Or 51% Principals) First/Last

First/Last

E-Mail Address: Telephone Number: Cell Number: Fax:

Applicant Intends to do business as: □ Sole Owner/Sole Proprietor………………………………………..……………… Complete Part B Partnership (Limited or Uniform) ……………………………………………….. Complete Part C All applicants □ must complete □ Corporation …………………………………………………………….………………… Complete Part D Parts G & H of □ Limited Liability Company ……………………………………...... ………. Complete Part E application. □ Joint Venture………………………………………………………………………………. Complete Part F DIVISION OF ECONOMIC DEVELOPMENT | BUSINESS REGULATORY DEPARTMENT POST OFFICE BOX 663 · WINDOW ROCK, AZ 86515 PHONE: (928) 871-6714 · FAX: (928) 871-7381 UPDATED: 08/13/2020 www.NavajoEconomy.org T H E N AVA J O N AT I O N

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

PART B. SOLE OWNERSHIP/SOLE PROPRIETOR: B.1. Give the name and address of the SOLE OWNER of the FIRM and indicate whether he/she is Navajo Indian (N), or Other Indian (OI). If Other Indian, list name of Tribe.

Social Security # Enrollment Status Name and Address and/or EIN# Census No. N/OI

1. Tribal Affiliation:

2. Tribal Affiliation:

3. Tribal Affiliation:

(PLEASE ATTACH COPY or COPIES OF CERTIFICATE OF INDIAN BLOOD)

If additional space is required, please attach all information on a separate sheet and label as following:

B.1. Continuation B.2. Attach any documents you may have that establish the ownership of your firm. (i.e., state license, city license, 8a certification)

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

PART C. PARTNERSHIP: Limited Partnership 5 N.N.C. § 4100; Uniform Partnership 5 N.N.C. § 3800

C.1. In which state is your firm registered? Date registered:

Please attach the Partnership Agreement (Limited) OR Partnership Statement (Uniform) and any amendments thereof, the Certificate of Limited Partnership (Limited) OR Statement of Partnership Authority (Uniform), By-Laws (optional) and Certificate of Good Standing.

C.2. Is the Partnership (Limited or Uniform) registered with the Navajo Nation? Yes No If YES, please attach the Partnership Agreement (Limited) OR Partnership Statement (Uniform) and any amendments thereof, the Certificate of Limited Partnership (Limited) OR Statement of Partnership Authority (Uniform), By-Laws (optional) and Certificate of Good Standing. If NO, please note that it is a requirement that a partnership must be registered with the Navajo Nation, 5 N.N.C. § 4100 (Limited) or 5 N.N.C. § 3800 (Uniform).

C.3. Provide the names and addresses of the PARTNERS of this FIRM and indicate whether they are Navajo Indian (N), Other Indian (OI), or Non-Indian (NI) in the spaces below. If Other Indian, list name of Tribe. Attach a copy of Certificate of Indian Blood for all Navajo/Other Indian Partners. To qualify for Priority Certification, firms applying as PARTNERSHIP status must be at least 51% Navajo or Other Indian owned and controlled.

1. Name Title Social Enrollment Status (N,OI,NI) Security # Census #

Address Tribal % Ownership Control Affiliation

2. Name Title Social Enrollment Status (N,OI,NI) Security # Census #

Address Tribal % Ownership Control Affiliation

If additional space is required, please attach all information on a separate sheet and label as following:

C.3. Continuation”. C.4. Required documents include Partnership Agreement.

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

PART D. CORPORATION (5 N.N.C §3100):

D.1. In which state is your firm incorporated? Date Incorporated? Please attach the Articles of Incorporation and any amendments thereof, the Certificate of Incorporation, By- Laws (optional) and Certificate of Good Standing.

D.2. Is the corporation registered with the Navajo Nation? Yes No If YES, please attach the Articles of Incorporation and any amendments thereof, the Certificate of Incorporation, By-Laws (optional) and Certificate of Good Standing. NO, please note that it is a requirement that a corporation must be registered with the Navajo Nation, 5 N.N.C. § 3100.

D.3. List the names and address of all DIRECTORS and OFFICERS of the CORPORATION. Indicate if they are Navajo or Other Indian. Attach a copy of Certificate of Indian Blood for all Navajo/Other Indian Directors and Officers. To qualify for Priority Certification, 51% or more stocks/shares must be held by Navajos and/or Other Indians. % Ownership of Office: Name/Address Tribal Affiliation: Stock/Share:

President

Vice President

Secretary

Treasurer

Director

D.4. The number of shares/stocks authorized:

Common Stock/Share Issued:

Preferred Stock/Share Issued:

Unissued Stock/Share:

TOTAL STOCK/SHARE AUTHORIZED:

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

PART E. LIMITED LIABILITY COMPANY (LLC) (5 N.N.C. § 3600):

E.1. In which State is your firm registered? Date registered:

Please attach the Articles of Organization and any amendments thereof, the Operating Agreement, Certificate of Good Standing and/or By-Laws (optional).

E.2. Is the LLC registered with the Navajo Nation? Yes No If YES, please attach the Articles of Organization and any amendments thereof, the Operating Agreement, Certificate of Good Standing, and/or By-Laws (optional). If NO, please note that it is a requirement that a LLC must be registered with the Navajo Nation, 5 N.N.C. § 3600.

E.3. List the names and address of all MANAGERS and MEMBERS of the LIMITED LIABILITY COMPANY (LLC). Indicate if they are Navajo or Other Indian. Attach a copy of Certificate of Indian Blood for all Navajo/Other Indian Managers and Members. To qualify for Priority Certification, 51% or more interests must be held by Navajos and/or Other Indians.

Office: Name/Address Tribal Affiliation: % of Interest

Manager’s

Member’s

E.4. Is the LLC manager managed OR member managed OR manager-member managed?

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

PART F. JOINT VENTURES: To qualify for Priority Certification, firms applying as JOINT VENTURE status must be at least 51% Navajo or Other Indian owned and controlled. Attach a copy of Certificate of Indian Blood for all Navajo/Other Indian party.

F.1. Full disclosure is required of all Joint Ventures. Attach a certified copy of the complete Joint Venture Agreement, including any amendments thereof.

F.2. Is the Navajo or Other Indian Party in the Joint Venture currently certified with the Business Regulatory Department? Yes No If YES, provide the name of the Business and Certification Number:

F.3. Is the Non-Indian Party Registered as a Corporation, Limited Liability Company, Limited Partnership OR Uniform Partnership? Yes No If YES, complete Part C, D OR E of the Application.

Name of Non-Indian Company:

Principal Officer: Telephone:

Mailing Address:

F.4. Joint Venture Bonding Capability? Yes No

F.5. Attach notarized Financial Statements for all parties of the Joint Venture which must have been prepared three months prior to application date. This must be similar to the form attached to this application (Exhibit A).

F.6. Monetary allowance for Administration (recording, support staff, office facilities and equipment, etc.) Management:

Managing Party: Monetary Allowance (Percentage):

F.7. Monetary allowance for Construction Management:

Managing Party: Monetary Allowance (Percentage):

F.8. Attach a list of equipment to be furnished by each Joint Venture party and specify the allowance of the use of the equipment. Specify if the equipment is owned or leased.

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

PART G. ORGANIZATION INFORMATION TO BE COMPLETED BY ALL APPLICANTS G.1. Attach a brief Organizational Chart and indicate all upper level management positions with names, titles, and indicate if Navajo/Other Indian or Non-Indian and describe the functions of the branches of the organization. G.2. List all Licensed Professional Staff within your organization and indicate if Navajo/Other Indian or Non-Indian: Name: Title: Tribal Affiliation:

G.3. Employment Breakdown: Number of Navajo Employees: Number of Other Indian Employees: Number of Non-Indian Employees: TOTAL WORKFORCE:

G.4. Describe your method of recruiting human resources:

G.5. Describe the physical location of your business establishment/s. i.e.: main office, warehouse/s, and inventory available at the site.

G.6. Attach a list of all projects for the last two (2) years and dollar amounts for each. Use the attached form or similar form (Exhibit B).

G.7. Has your company ever filed for bankruptcy? If yes, please explain. Yes No

G.8. Describe the type of goods and/or services your firm can provide to projects throughout the Navajo Nation with your own employees and equipment, rather than by subcontract. NOTE: Priority Certification and Certificate Issuance will be limited to these activities listed as goods and/or services. (60 words or less)

JONATHAN NEZ | PRESIDENT MYRON LIZER | VICE PRESIDENT

PART H. CERTIFICATION

H.1. By signing below, I certify and attest that all information contained herein is complete, true and correct. I further understand that the Business Regulatory Department, Division of Economic Development must give its approval before this Navajo or Other Indian owned and controlled firm can be considered or accepted as a Certified Priority firm for project(s) within the exterior boundaries of the Navajo Nation.

I FURTHER UNDERSTAND THAT THE CERTIFICATION IS ONLY VALID FOR ONE (1) YEAR.

SIGNATURES OF OWNERS, PARTNERS, OFFICERS, MEMBERS, MANAGERS OF THE BUSINESS

Date: Signature: Title:

DIVISION OF ECONOMIC DEVELOPMENT | BUSINESS REGULATORY DEPARTMENT POST OFFICE BOX 663 · WINDOW ROCK, AZ 86515 PHONE: (928) 871-6714 · FAX: (928) 871-7381 UPDATED: 08/13/2020 www.NavajoEconomy.org (Exhibit B ) PAST PROJECTS DATE & NO. OF COST PROJECTS YEAR EMPLOYEES OWNER OF PROJECT(S) LOCATION APPROXIMATE 1 Name: Address:

PH.# 2 Name: Address:

PH.# 3 Name: Address:

PH.# 4 Name: Address:

PH.# 5 Name: Address:

PH.# 6 Name: Address:

PH.# 7 Name: Address:

PH.# 8 Name: Address:

PH.# 9 Name: Address:

PH # Office of the Navajo Tax Commission

Calendar Year 2020

Applicants applying for funds below $5,000 are not required to submit tax documents for procurement.

Please return the original signed form 100 to the Office of Navajo Tax Commission.

Drop off at office location at: Karigan Professional Building, Suite 115 Highway 264, 100 Taylor Road St. Michaels, Arizona 86511

Mailing Address: Office of the Navajo Tax Commission PO Box 1903 Window Rock, Arizona 86515

Telephone Number: (928) 871-6681 Fax Number: (928) 871-7608 Website: www.tax.navajo-nsn.gov Email: [email protected]

There may be a requirement to submit an additional Form 200. Contact Navajo Tax Commission on further assistance. The form 200 is attached for reference. FORM 100

DESIGNATION OF INDIVIDUAL EIN/TIN/SSN : Calendar Year 2020 PLEASE PRINT LEGIBLY. Please refer to instructions to complete this form.

Business Name :

Nature of Business :

1. Designee(s) Information

Name :

Title :

Mailing Address :

City, State, Zip Code :

Telephone Number :

Fax Number :

E-mail Address :

2. Navajo Nation Mailing Address & Telephone Number (if different from Section 1)

Telephone :

3. This form applies to : (check one only) 4. Type of Business : (check one only) ALT HOT SALES Corporation Partnership BAT JFT SEV Joint Venture Sole Proprietorship FET LIQ TOB Other (Specify)

5. Month End of Accounting Year: 6. Accounting Records kept on: Cash Accrual 7. Physical Address of where records are located (Street, City, and State) : No post office box numbers

I declare that the information contained in this document and any attachments thereto is true and correct to the best of my knowledge and belief pursuant to all Navajo Nation Laws and Regulations.

x Taxpayer or Duly Authorized Agent Signature Telephone Number

Print or Type Name Date

ONTC Form 100-2020 Revised: 10/01/19 FORM 200 DECLARATION OF INTEREST IN LEASE

Assessment Date : January 1, 2020 In accordance with 24 NNC Sec. 211 (a) each owner must file a declaration of its interest in any lease on or before April 1st following each assessment date, except for business site leases, which are due May 15th following each assessment date. The Office of the Navajo Tax Commission (ONTC) may, by Form 245 or regulation, require additional information and documents, which it deems necessary for proper and efficient administration of the tax.

1. Taxpayer Federal TIN/SS/EIN # :

2. Name of Taxpayer :

3. Business Address : POB or Street City St. Zip E-mail: Telephone No. :

4. a. Type of Operation Conducted on Lease : Production of Oil, Gas Hydrocarbons, etc ROW Lease/Permit (Pipeline, Transmission, etc) Mining Lease (Coal, Sand, Gravel, Uranium, etc) Permits (Revocable, Temporary, etc) Communication System (Cellular, Microwave, Paging, Multi-County Contractor (Construction, Drilling, etc) Reseller, Telephone Provider of Service or Equipment or REA) Electric Power (Distribution, Generation, Transmission, REA) BUSINESS SITE LEASE RESIDENTIAL Other, specify : 4. b. Type of Land Operating on: (Circle one) Tribal Trust or Tribal Fee Private State BLM Allottment OTHER: 5. Name of Operator/Business :

6. Lease/Permit No. : 7. Your Percent Interest in Lease/Well/Permit : Well/Unit Name: WI ORR OP OTHER

8. a. Do You Own Interests In More Than One Lease? Yes No 8. b. Effective Date of assignment of interest: If answer is yes, a separate Form 200 must be completed for each lease, interest and/or permit. (MM/DD/YYYY) 9. a. Are You Related To Any Other Lease Owner? Yes No 9. b. Name and Address of RELATED OWNER: 9. c. Name and Address of LESSOR (aka Base lease owner): 10. Physical Location of Lease (Township, Range, Section) : State : County : Agency: Chapter: 11. CHANGES TO THE STATUS OF LEASE: IF SOLD OR TRANSFERRED, New Owner's Name & Address: SOLD LEASE or INTEREST LEASE TRANSFERRED Owner Name/Business Name City ST ZIP

EXPIRED LEASE New Owner's Telephone Number : PENDING APPROVAL New Owner's Email Address:

EMERGENCY OPERATING AGRMT. Date Lease/Permit Expired : REVOCABLE USE PERMIT Date Property Was Sold : NON-PROFIT How Much Was Property or Interest Sold for ($) : OTHER: I declare that the information contained in this document and any attachments thereto is true and correct to the best of my knowledge and belief pursuant to all Navajo Nation laws and regulations. x Taxpayer or Duly Authorized Agent Signature Print or Type Name Date

PIT FORM 200 www.tax.navajo-nsn.gov Revised: 011/04/2020