VENDOR_QUESTIONNAIRE.doc

VENDOR QUESTIONNAIRE

FROM:

Phoenix Job Corps Center

Date: _________________

Education Management Corporation

Purchasing Department

518 S. 3rd Street

Phoenix, AZ 85004

602-322-2808 (voice)

602.322.6603 (fax)

ATTN:

To whom it may concern:

Completion of this form and W-9 is required in order for your business to receive full payment for goods and services. If you are a small business, please read the attached small business certification and check the appropriate designation(s) below.

Type of Service Provided: _______________________________________________________

Company Name: ______________________________________________________________

Street Address: _______________________________________________________________

City:

_____________________________ State & Zip: ___________________________ Remittance Address (if different): _______________________________________________

City:

__________________________ State & Zip: ______________________

Telephone #: _________________________ Fax #: _________________________

Check all Categories that Apply:

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1. Small Business

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2. Small Disadvantaged Business (Must be SBA Certified)

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3. Women Owned Small Business

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4. HUBZone Small Business (Must be SBA Certified)

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5. Veteran Owned Small Business

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6. Service-Disabled Veteran Owned Small Business

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7. Historically Black College/University or Minority Institution

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8. Large Business

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9. Government

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10. Non-Profit

Primary NAICS Code (for SBA Certified business): _________________________

Signature and Title of Individual Completing Form

Date

SMALL AND SMALL DISADVANTAGED BUSINESS CERTIFICATION

Education Management Corporation participates in the Government’s Small and Small Disadvantaged Business programs. This requires written certification from our suppliers and contractors as to their business status. Please furnish the information requested below.

1.0 Small Business – An enterprise independently owned and operated, not dominant in its field and meets employment and/or sales standards developed by the Small Business Administration. See 13 CFR 121.201

1.a Small Disadvantaged Business – a Small Business Concern owned and controlled by socially and economically disadvantaged individuals; and

(1) Which is at least 51% owned by one or more socially and economically disadvantaged individuals; or in the case of any publicly owned business, at least 51% of the stock of which is owned by one or more socially and economically disadvantaged individuals and

(2) Whose management of daily operations is controlled by one or more such individuals. The contractor shall presume Black Americans, Hispanic Americans, Native Americans (such as American Indians, Eskimos, Aleuts and Native Hawaiians), Asian-Pacific Americans and other minorities or any other individual found to be disadvantaged by the Administration pursuant to Section 8 (a) of the Small Business Act and

(3) Is certified by the SBA as a Small Disadvantaged Business.

1.b Women-Owned Business Concern – A business that is at least 51% owned by a woman or women who also control and operate it. Control in this context means exercising the power to make policy decisions. Operate in this context means being actively involved in the day-to-day management.

1.c HUBZone Small Business Concern – A business that is located in historically underutilized business zones, in an effort to increase employment opportunities, investment and economic development in those areas as determined by the Small Business Administration’s (SBA) List of Qualified HUBZone Small Business Concerns.

1.d Veteran-Owned Small Business Concern – A business that is at least 51% owned by one or more veterans; or in the case of any publicly owned business, at least 51 % of the stock of which is owned and controlled by one or more veterans and the management and daily business operations of which are controlled by one or more veterans.

1.e Service Disabled Veteran-Owned Small Business - A business that is at least 51% owned by one or more service disabled veterans; or in the case of any publicly owned business, at least 51 % of the stock of which is owned and controlled by one or more service disabled veterans and the management and daily business operations of which are controlled by one or more service disabled veterans. Service disabled veteran means a veteran as defined in 38 U.S.C. 101(2) with a disability that is service connected as defined in 13 U.S.C 101(16).

Notice: In accordance with U.S.C. 645(d)., any person who misrepresents a firm’s proper size classification shall (1) be punished by imposition of 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.

If you have difficulty determining your size status, you may contact the Small Business Administration at 1-800-U-ASK-SBA OR 202-205-6618. You may also access the SBA website at www.sba.gov/size or you may contact the SBA Government Contracting Office at 817-684-5301. (Rev. 8/2008)

NOTE:

This certification is valid unless you notify us of any changes. It is your responsibility to notify us if your size or ownership status changes.