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Vendor Application Form

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Vendor Application Form
Submitted with Form W-9

Please enter the information below, sign it, and fax it to Procurement at (508) 457-2192.
- - - -
Invoice Remittance Address
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Business Type Classification (please check all that apply)
HUB Zone Firm* Service Disabled Veteran Owned
Small Business Disabled
Large Business (500+) Nonprofit Organization
Disadvantaged Business 8(a)* Historically Black College/University
Woman Owned Business Foreign Supplier
Minority Owned Business  
Veteran Owned Business  
*Hub Zone and Small Disadvantaged Business must provide a copy of their certificate with this form.
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.

Goods or Service Category
Goods Service
Computer Supplies Building Trades/Contractors
Electronic Supplies Consulting Services
Office Supplies/Furniture/Equipment Distributor
Marine/Rigging Shop Supplies Maintenance
Other Goods (please describe) Manufacturer
  Medical Services (for profit)
  Ship Agent Services
  Transportation Services
  Other Services (please describe)
Affiliation to WHOI
To the best of your knowledge, is the company controlled, or actively influenced (with reagard to any proposed transaction with the institution) by you, a member of your immediate family or any employee?
No
Yes (please explain)
Debarment
My firm is not currently debarred, suspended, or proposed for debarment by any federal entity, and I agree to notify the institution of any change in status.
No
Yes (please explain)


Last updated: April 18, 2014
 


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