Vendor Information
Name:
TIN/SSN:
Business Mailing Address
Address:
City:
State:
Phone:
Fax:
Contact:
Email:
Invoice Remittance Address
Address:
City:
State:
Phone:
Fax:
Contact:
Email:
Required
Vendor Authorized Signer Name: ________________________
Phone:
________________
Vendor Signature: ____________________________________
Date:
_____/_____/_____
Tax and Withholding Information (please select
one)
Business Type Classification (please check all
that apply)
*FAR Clause 52.219-1(d) (2) Under 15
U.S.C 645(d), any person who misrepresents a firm’s status as a small, HUBZone
small, small disadvantaged, or women-owned small business concern in order to
obtain a contract to be awarded under the preference programs established
pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act or any other
provision of Federal law that specifically references sections 8(d) for a
definition of program eligibility, shall: (i) Be punished by imposition of fine,
imprisonment or both; (ii) Be subject to administrative remedies, including
suspension and debarment and (iii) Be ineligible for participation in programs
conducted under the authority of the Act.
**Hub Zone and Small
Disadvantaged Business must provide a copy of their certificate with this
form.
Purchasing Key (please select one)
