Supplier Information and Business Size Classification



Supplier Information and Business Size ClassificationCompany Name: FORMTEXT ?????SAM Registered:Yes FORMCHECKBOX No FORMCHECKBOX Physical Address: FORMTEXT ?????DUNS #: FORMTEXT ?????Remit to Address: FORMTEXT ?????Cage Code: FORMTEXT ?????Website Address: FORMTEXT ?????Phone Number: FORMTEXT ?????NAICS Code: FORMTEXT ?????Date Founded: FORMTEXT ?????Corporation FORMCHECKBOX Partnership FORMCHECKBOX Sole Owner FORMCHECKBOX President: FORMTEXT ?????Vice President: FORMTEXT ?????Treasurer: FORMTEXT ?????Secretary: FORMTEXT ?????Partners: FORMTEXT ?????Sole Owner: FORMTEXT ?????ContactsNameExt.#Fax #EmailAble to Commit to Company Assets?Inside Sales FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Expeditor FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Outside Sales FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Pricing Inquiries FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Contracts FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Insurance Issues FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Quality Assurance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????A/R Point of Contact A/R Name FORMTEXT ?????Phone FORMTEXT ?????Payment Terms FORMTEXT ?????Title FORMTEXT ?????Fax FORMTEXT ?????e-mail FORMTEXT ?????AlternateName FORMTEXT ?????Phone FORMTEXT ????? FORMTEXT ?????Title FORMTEXT ?????Fax FORMTEXT ?????e-mail FORMTEXT ?????If you are self-certifying as a Small Business, please verify the information below for the work you are being requested to perform. Check the appropriate “Self Certifications” boxes, provide other information as requested, sign, date, and return this form.SELF CERTIFICATIONS( Check the appropriate box) : FORMCHECKBOX Small Business FORMCHECKBOX Large Business FORMCHECKBOX Small Disadvantaged Business FORMCHECKBOX SBA certified HUBZone Small Business FORMCHECKBOX Woman-Owned FORMCHECKBOX Minority-Owned FORMCHECKBOX Veteran-Owned FORMCHECKBOX Service-Disabled Veteran-Owned FORMCHECKBOX SBA certified 8(a) Small BusinessNOTE: HUBZone and 8(a) small business companies are required to be certified through the Small Business Administration (SBA). Additional forms and information may be obtained through the SBA’s web site at () or call (800) 558-0884. HUBZone web site information can be found at () or call (202) 205-8885.You may wish to review the definitions for the above categories in the Federal Acquisition Regulation (FAR) 19.7 or 52.219.8 (.far). If you have difficulty ascertaining your size status, please refer to the SBA’s website at size or contact your local SBA office.As stated in FAR 52.219-1, under 15 U.S.C 645(d), any person who misrepresents its size shall (1) be punished by a fine, imprisonment, or both (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act.Point of contact for this request: FORMTEXT ?????Telephone: FORMTEXT ????? Email: FORMTEXT ????? ___________________________________(Print Name)___________________________________(Signature)___________________________________(Title)___________________________________(Date)INTERNAL USEHubzone and 8(a) status has been verified in the Small Business Administration (SBA) Dynamic Small Business Search Database as of ________.___________________________________(Print Name)___________________________________(Signature)___________________________________(Title)___________________________________(Date)NOTE: (1) NAICS codes are needed for the year end supplementary report for small disadvantaged businesses ( by 3-digit NAICS subsector) that the prime contractor is required to submit to the Government annually pursuant to the FAR 52.219.9(1)(2)(iii). ................
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