3._HJCA_CPO12-002_Vendor_Acknowledgement_Form.doc

Vendor Acknowledgement

From:

Hartford Job Corps Center Date: April 2015 Street:

100 William Shorty Campbell Street City:

Hartford State:

CT

Zip Code: 06016

Phone:

860-952-1738 Fax: 860-952- 0231 Email; patricia.uccello@etrky.com

Completion of this form and a W-9 is required by our company. If you are a small business, check the appropriate designation(s) below and attach certificates if SBA certified.

Vendor Name:__________________________________________________ Street ________________________________________________________ City, State, and Zip Code: ________________________________________ Phone:

Fax:

Email: ____________________________ Duns #:____________________________ Type of Goods/Services Provided:

Primary NAICS Code (for all business): ___________________________________________

Check all Categories that Apply:

1. Small Business

2. Small Disadvantaged Business (SBA Certified)

3. Women Owned Small Business

4. HUBZone/8a Small Business (SBA Certified)

5. Veteran Owned Small Business

6. Service-Disabled Veteran Owned

Small Business

7. Historically Black College/University or Minority Institution

8. Alaskan Native Corporation (ANC) & Indian Tribes

9. Large Business

10. Government

11. Non-Profit

Please attach the following:

· Certificate of Liability Insurance

· Malpractice and Controlled Substance (if applicable)

· Business License (if state regulated; NY not required)

· Performance Bonds

· Construction Bonds

· Certifications (if applicable)

Vendor Acknowledgement By signing below: I acknowledge that I understand that the Authorized Purchasing Personnel, FAR clauses 52.222-6 (Davis Bacon Act), 52.222-41 (Service Contract Act of 1965), 32.905 Payment Documentation and Process, FAR Clauses and Terms and Conditions are on the website www.etrky.com, and that my company is subject to these terms and conditions and FAR clauses. I also understand that the Job Corps Center/Academy is sales tax exempt, and to the best of my knowledge, the company is not or has not acted in any way to cause disbarment or suspension (as outlined in FAR clause 52.209-6) from any federal contracts or funds. I acknowledge that by knowingly making false statements or misrepresentation of small business status, I am subject to criminal penalties (FAR 52.219-8).

Printed Name

Signature

Date

CPO12-002

Modified 7/11/2014