Contractor Info Sheet Abidjan.docx

Contractor/Vendor Information Sheet

Please fill in all information below, type or print information clearly. Please complete the following questions and return to Mohammed Haque at HaqueMN@state.gov by 3:00PM EST, February 16, 2023.

Legal Business Name: ____________________ Tax ID No: UEI No:

Mailing Address:

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: African American Owned Business

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 country? Yes____ No____

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

Can you obtain a security license in country under your legal business name or a wholly owned subsidiary of your business? Yes ____ No____