Enclosure 3 AMS-Form-010.docx

DOCX document 30 KB Posted

Attached to
Radioactive Waste Railroad Logistics and Transportation from Upton, NY to Clive, Utah
Solicitation number
387323
Issued by

View the file

Other files

File Type Posted
Amendment 2 to RFQ 387323.pdf PDF
Amendment 1 to RFQ 387323.pdf PDF
Enclosure 1 Draft Contract 387323.pdf PDF
Enclosure 4 AMS-Form-043.docx DOCX document
Enclosure 2 AMS-Form-009.docx DOCX document
RFQ 387323.pdf PDF

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

ENCLOSURE 3

BROOKHAVEN NATIONAL LABORATORY

ACQUISITION MANAGEMENT FORM

Form No. AMS-Form-010 Revision No. 8.0

REPRESENTATIONS AND CERTIFICATIONS – SUPPLIER INFORMATION

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

Form No. AMS-Form-010

Revision No. 8.0

APPROVED BY:

L. McKnight/9/24/2020

PPM Manager/Date

REPRESENTATIONS AND CERTIFICATIONS – SUPPLIER INFORMATION

Company Name
.
Certifying Official
Address Line 1
.
Name:
.
Address Line 2
.
Date:
.
City, State, Zip
., . .
Vendor Code:
Country
.
Buyer/CS
Emily Mastronardi
Phone Number
.
Fax Number
.
Email Address
.

Taxpayer Identification Taxpayer Identification Number (TIN).

|_|TIN: .
|_|TIN is not required because:
|_|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;
|_|Offeror is an agency or instrumentality of the Federal Government.

|_| Check if you require a 1099 Form for Tax Purposes

Common parent

|_|Offeror is not owned or controlled by a common parent
|_|Name and TIN of common parent:

Name .

TIN .

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: https://www.census.gov/eos/www/naics/ and enter a keyword for that product or service.

To look up the size standard for the NAICS code you picked above, go to: https://www.sba.gov/document/support--table-size-standards

NAICS Code . Size Standard: .

Representations Select one of the following business classifications

|_|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).

Only for small business concerns, check all of the following that apply*.

|_|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 Mary Rogers, Small Business Liaison Officer, Email address mrogers@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 Mary Rogers, Small Business Liaison Officer, Email address mrogers@bnl.gov.

Definitions 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

Date Printed 10/14/2020 Date Approved 09/24/2020

File details come from the government source that posted it. Updated .