Form10.pdf

PROCUREMENT AND PROPERTY MANAGEMENT DIVISION

BROOKHAVEN NATIONAL LABORATORY

Managed by Brookhaven Science Associates, LLC under contract to the U.S. Department of Energy

ACQUISITION MANAGEMENT SYSTEM FORM

REPRESENTATIONS AND CERTIFICATIONS - SUPPLIER INFORMATION

Form No. AMS-Form-010

Revision No. 7

APPROVED BY:

D. Rawlings / 05/15/12

PPM Manager/Date

Company Name

Name:

Contractor Certifying Official

Address line 1

Address line 2

City, State, Zip

Country

Phone Number

Fax Number

Email Address

Date:

Vendor Code:

Buyer/CS:

Taxpayer Identification Number (TIN)

TIN Number

TIN is not required because the Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States; Offeror is an agency or instrumentality of a foreign government; or Offeror is an agency or instrumentality of the Federal Government.

Check if you require a 1099 for Tax Purposes

Common Parent

Offeror is not owned or controlled by a Common Parent Name and TIN of Common Parent

Name

TIN

For BSA use only

To save forms with data use Adobe Acrobat Reader Version 9 or later from http://www.adobe.com/

Small Business Program Representations

In order to self-certify below that you are a small business you must identify your North American Industry Classification System (NAICS) Code for the product or service you are providing to Brookhaven Science Associates (BSA)/Brookhaven National Laboratory (BNL). You must also identify the applicable small business size standard for that NAICS Code. To be considered a small business against a Size Standard that is for a number of employees the company (including the common parent if any) must employ fewer than the size standard lists and for a Size Standard based on annual sales the company (including the common parent if any) must have an average sales for the past three (3) years that are less than that value.

To look up the NAICS code for the product or service that you are selling to BSA/BNL, go to:

http://www.census.gov/naics/2007/index.html and enter a keyword for that product or service.

To look up the size standard for the NAICS code you picked above, go to:

http://www.sba.gov/sites/default/files/Size_Standards_Table.pdf

NAICS Code Size Standard

Representations - select one of the options below.

The offeror represents that it is a large business concern (BIG) The offeror represents that it is a foreign business concern (FRG) The offeror represents that it is an educational institution (EDU) The offeror represents that it is a federal government agency (FED) The offeror represents that it is a local government agency (LOC) The offeror represents that it is a government owned contractor operated concern (GOC) The offeror represents that it is a non-profit concern (NON) The offeror represents that it is a small business* concern (SML)

*Offerors that represents itself as a small business concern shall additionally check any of the boxes below that are applicable

The offeror represents that it is a small disadvantaged business concern as defined in 13 CFR 124 (MNR).

The offeror represents that it is a woman owned small business concern (WOM).

The offeror represents that it is a veteran owned small business concern (VET).

The offeror represents that it is a service disabled veteran owned small business concern (DVT).

The offeror represents that it is a US Small Business Administration certified 8(a) small business concern as defined in 13 CFR 124 and that no material change in ownership and/or control has occurred since it was certified by the U.S. Small Business Administration. Please note that a copy of your most recent 8(a) certification letter must be sent to Jill Clough-Johnston, Small Business Liaison Officer, Email address clough@bnl.gov.

The offeror represents that it is a HUBZone small business concern (HUB) listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration. No material change in ownership and/or control, principal office, or HUBZone employee percentage has occurred since it was certified by the Small Business Administration in accordance with 13 CFR part 126. Please note that a copy of your most recent HUB-Zone certification letter must be sent to Jill Clough-Johnston, Small Business Liaison Officer, Email address clough@bnl.gov.

Date Approved: 05/15/12AMS-Form-010, Rev. 7 Page 2 of 4

Page 3 of 4 Date Approved: 05/15/12AMS-Form-010, Rev. 7

Re: Electronic Fund Transfer [AUTOMATIC DEPOSITS (ACH CREDITS)]

Managed by Brookhaven Science Associates, LLC

Authorization Information

BSA Procurement Representative

Seller/Company Name or DBA

Vendor Number (if applicable)

I hereby authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments to our company by initiating ACH (Automated Clearing House) credit entries or correcting entries to the account indicated below and the financial institution named below, to credit the same to such account. This authorization will remain in effect until the BNL/BSA, the Procurement Representative receives written notification to terminate same. It is my understanding that credit authorizations may be revoked only by notification by the originator as described in the rules and regulations specified by NACHA (National Automated Clearing House Association). If possible, please provide a voided copy of a check to assist with accurate data entry.

Financial Information

Financial Institution

Routing/Transit/ABA # (Bank 9-digit id)

Checking Account #

Email address to Confirm Transfer of Funds into Account

Print Name Title

Telephone No Date

Signed: __________________________________ (Signature)

Page 4 of 4 Date Approved: 05/15/12AMS-Form-010, Rev. 7

Definitions Certifying Official Means the individual at the organization identified in the Company Name Box that certifies the information on this form is accurate and complete. This is not a BSA Employee.

Taxpayer Identification Number (TIN) Means the number required by the Internal Revenue Service (IRS) to be used by the offeror in reporting income tax and other returns. The TIN may be either a Social Security Number or an Employer Identification Number.

Common Parent Means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member.

For definitions of Small Business and Small Business subcategories, go to http://www.bnl.gov/ppm/SDB/DefinitionNAICS.asp

Payment Requirements Effective immediately, in order to do business with BSA, suppliers will be required to provide banking information to allow for Electronic Funds Transfer (EFT) payments. Please include a notification e-mail address where transaction postings will be sent when each transfer is completed.

PROCUREMENT AND PROPERTY MANAGEMENT DIVISION

Managed by Brookhaven Science Associates, LLC under contract to the U.S. Department of Energy

ACQUISITION MANAGEMENT SYSTEM FORM

REPRESENTATIONS AND CERTIFICATIONS - SUPPLIER INFORMATION

Form No. AMS-Form-010

Revision No. 7

APPROVED BY:

D. Rawlings / 05/15/12

PPM Manager/Date Contractor Certifying Official Taxpayer Identification Number (TIN) Common Parent For BSA use only To save forms with data use Adobe Acrobat Reader Version 9 or later from http://www.adobe.com/ Page of Small Business Program Representations In order to self-certify below that you are a small business you must identify your North American Industry Classification System (NAICS) Code for the product or service you are providing to Brookhaven Science Associates (BSA)/Brookhaven National Laboratory (BNL). You must also identify the applicable small business size standard for that NAICS Code. To be considered a small business against a Size Standard that is for a number of employees the company (including the common parent if any) must employ fewer than the size standard lists and for a Size Standard based on annual sales the company (including the common parent if any) must have an average sales for the past three (3) years that are less than that value.

To look up the NAICS code for the product or service that you are selling to BSA/BNL, go to:

http://www.census.gov/naics/2007/index.html and enter a keyword for that product or service.

To look up the size standard for the NAICS code you picked above, go to:

http://www.sba.gov/sites/default/files/Size_Standards_Table.pdf Representations - select one of the options below.

*Offerors that represents itself as a small business concern shall additionally check any of the boxes below that are applicable Date Approved: 05/15/12 AMS-Form-010, Rev. 7 Page of Page of Date Approved: 05/15/12 AMS-Form-010, Rev. 7 Re: Electronic Fund Transfer [AUTOMATIC DEPOSITS (ACH CREDITS)]

BROOKHAVEN NATIONAL LABORATORY

Managed by Brookhaven Science Associates, LLC

Authorization Information

I hereby authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments to our company by initiating ACH (Automated Clearing House) credit entries or correcting entries to the account indicated below and the financial institution named below, to credit the same to such account. This authorization will remain in effect until the BNL/BSA, the Procurement Representative receives written notification to terminate same. It is my understanding that credit authorizations may be revoked only by notification by the originator as described in the rules and regulations specified by NACHA (National Automated Clearing House Association). If possible, please provide a voided copy of a check to assist with accurate data entry.

Financial Information

Signed: __________________________________ (Signature)

Page of Date Approved: 05/15/12 AMS-Form-010, Rev. 7 Definitions Certifying Official Means the individual at the organization identified in the Company Name Box that certifies the information on this form is accurate and complete. This is not a BSA Employee.

Taxpayer Identification Number (TIN) Means the number required by the Internal Revenue Service (IRS) to be used by the offeror in reporting income tax and other returns. The TIN may be either a Social Security Number or an Employer Identification Number.

Common Parent Means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member.

For definitions of Small Business and Small Business subcategories, go to http://www.bnl.gov/ppm/SDB/DefinitionNAICS.asp

Payment Requirements Effective immediately, in order to do business with BSA, suppliers will be required to provide banking information to allow for Electronic Funds Transfer (EFT) payments. Please include a notification e-mail address where transaction postings will be sent when each transfer is completed.

8.0.1291.1.339988.308172