Supplier Certification Form - FHI 360
| |FHI 360 VENDOR CERTIFICATION FORM |
|To be able to do business with FHI 360, VENDORS/CONTRACTORS must complete this form in addition to providing a current IRS registered form; W9 and Banking details |
|Please provide information legibly | |
|Legal Name: | |
|(last name first) |________________________________________________________________________ |
| | |
|Trade or Business Name | |
|(e.g. Doing Business As): | |
| |Enter individual’s name. |
| | |
| | |
| |________________________________________________________________________ |
| Enter the company/individual name as it appears under your Federal Identification and/or |
|Registered Name within |
| |
|Mail CONTRACTING DOCUMENT to: |Mail PAYMENTS (leave blank if address is the same) to: |
|Attn: |________________________ |Title: |_________________ |
| |(a P.O. box cannot be accepted for a purchase order address) |P.O. Box: |____________________________________________________ |
|City: |____________________________________________________ |City: |____________________________________________________ |
|State: |________________________ |Zip: |_________________ |
|Telephone: |____________________________________________________ |Telephone: |____________________________________________________ |
|Fax: |____________________________________________________ |Fax: |____________________________________________________ |
|Email: |____________________________________________________ |Email: |____________________________________________________ |
| |(If additional purchasing or payment sites are applicable, please | | |
| |attach additional site information.) | | |
| |
|(Double click in boxes to electronically apply check-mark) |Taxpayer Identification Number: |
|Type of Organization (Check only ONE): |Federal ID # | | Social Security # |
| Individual Recipient (not owning a business) | | | ______________________________ |
| Sole Proprietorship ______________________________ | | Consultant 1099 |
| | |______________________________ |
|Partnership ______________________________| | |
| Incorporated Business |______________________________ VAT Registration # (as |
| |applicable) |
| Nonprofit Organization | ______________________________ ______________________________|
| Government Entity | ______________________________ |
| Limited Liability Company (LLC) |
|(Enter tax classification (D=disregarded entity, C=corporation, P=partnership) ______ |
|Contract payment and reimbursement for expenses are customarily wired through a bank transfer. The name in which the bank account is operated, the name of the bank, |
|and the |
|account number must be entered below. This information constitutes a part of initiated Contractor Agreement where applicable. |
|BANK NAME |
| |
|ISO CURRENCY CODE |
| |
| |
|BANK ADDRESS 1. |
| |
|BENEFICIARY ACCOUNT NAME |
| |
| |
|BANK ADDRESS 2. |
| |
|BENEFICIARY ACCOUNT NUMBER |
| |
| |
|BANK COUNTRY |
| |
|ABA ROUTING # |
| |
| |
|BANK TELEPHONE # |
| |
|SWIFT BIC CODE |
| |
| |
|BANK FAX # |
| |
|IBAN |
| |
| |
|BANK BRANCH NAME |
| |
|CNAPS |
| |
| |
|BANK BRANCH ADDRESS |
| |
|BANK CONTACT NAME |
| |
| |
|FHI 360’s (in accordance with FAR 52.219-9(e)(5)) policy is for Small Businesses, Small Disadvantaged Businesses, Minority Businesses, Woman Owned Small Business, |
|Veteran Owned Small Businesses, Service Disabled Veteran Owned Small Businesses, and HUB Zone business entities to have the maximum practicable opportunity to |
|participate in the performance of subcontracts and/or prime contracts awarded to FHI 360. Contact the Small Business Administration resources for more information |
|regarding this process; . |
|As applicable/North American Industry Classification System (NAICS) Code () |DUNS No. ______________ |
|The NAICS size standard is ___________________ Dollars Employees |NAICS Code: ______________ |
|Business Status |Small Business Classification (Check all that apply): |
| |(The Federal Gov may impose a penalty against firms misrepresenting their business size, disadvantaged and/or HUB Zone status) |
|(Based on NAICS code | | | | | | |
|listed above): |Small Disadvantaged |Women-Owned Small |Veteran-Owned Small|Service Disabled |HubZone Business |Minority or Alaskan |
| |Business (8(a) must |Business |Business |Veteran-Owned Small |(must provide a copy of|Business Owned |
| |provide a copy of | | |Business |certification issued) | |
| |certification issued | | | | | |
| |by SBA) | | | | | |
| Large Business | | | | | | |
|Small Business | | | | | | |
| | |
|SUPPLIER CERTIFICATION: Under penalties of perjury, I certify that (via electronic receipt or manual signature) that to the best of my knowledge the information |
|provided is adequate and sufficient. |
|____________________________________________________ |__________________________ |
|Signature (person authorized to commit your organization to contractual obligations) |Date Signed |
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