Supplier_Information_form.pdf

Savannah River Remediation LLC Supplier Information Form

For SRR Use Only

TIN:

OSR 46-9

(Rev 2011-05-25)

Please complete and sign this form. Print or type. *Indicates a required field.

Part I General Information

*Company Name:

A Subsidiary/Division of:

*Street Address:

*Contact Name:

*Email Address:

Web Site Address:

*Contact Phone: Toll Free: *Fax:

*State: *Zip: *Country Name:

*Country Name:

(other than USA) *City

Part II Business Specific Information

*DUNS Number: *Federal Identification Number: *Incorporated: Yes No

Part III *Socio-Economic Information Is your business (please select all that apply) Minority Business:

Service Disabled Veteran:

State/Local Government:

Woman-Owned:

Foreign-Owned:

Veteran-Owned:

Educational Institution:

Non-Profit:

HCBU:

Certified 8(a):

Certified HUBZone:

SDB: Federal Government:

exit date:

entrance date:

Part IV *Company Classification

Please provide the primary NAICS codes for your company (a maximum of 20) Large Business NAICS: Please list all six-digit NAICS codes which you are classified as a Large Business.

Small Business NAICS: Please list all six-digit NAICS codes which you are classified as a Small Business.

Notice: Under 15 USC 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 sections 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references section 8(d) for a definition of program eligibility, shall — (1) Be punished by imposition of fine, imprisonment, or both; (2) Be subject to administrative remedies, including suspension and debarment; and (3) Be ineligible for participation in programs conducted under the authority of the Act.

I hereby certify that the information provided on this form is accurate and complete.

Authorized Signature: Date: