23R0166_Contractor Info Sheet.pdf

Contractor/Vendor Information Sheet-19AQMM23R0166

Please fill in all information below, type or print information clearly. Please complete the following questions and return to Daniel Smith at Smithdd@state.gov and carbon copy Ms. Crystal M. Sutliff at

Sutliffcm@state.gov addressing each of the above requirements by 1:00PM EST, May 23, 2023.

Legal Business Name:

Tax ID No: DUNS No:

Mailing Address:

City, State, Zip Code:

Country:

Toll Free Number: Website Address:

Point of Contact:

Phone Number: Fax:

E-mail Address:

Country of Origin U.S. Firm ___

Foreign Vendor ___

Country: ___________

Size of Business:

Large ___

Small ___

Corporate Status:

Corporation ___ S-Corporation ___

Sole Proprietorship ___

Partnership ___

Other: _______________

Type of Ownership:

Woman ___

Veteran-owned___ (Service-disabled ____)

Minority___

None of the Above ___ Other: _________________

Socio-Economic Status:

8(a) Status ___

HUBZone___ Disadvantaged____

None of the Above ___

Other:_________________

Registered in SAM: Yes No _

DCAA-approved accounting practices: Yes No _

Do you currently do business in Mozambique? Yes____ No____

Have you performed guard services under NAICS code 561612? Yes____ No____

Can you obtain a security license in Mozambique under your legal business name or a wholly owned subsidiary of your business? Yes____ No____