3_Vendor_Acknowledgement_Form.docx

From: Northlands Job Corps Center Date: December 1, 2015

Zip Code: 05491 Phone: 802-877-0149 Fax: 802-877-3422 Email: frank.sheldon@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: ________________________________________

Email: ____________________________ Duns #:____________________________

Primary NAICS Code (for all business): ___________________________________________

Vendor Acknowledgement

CPO12-002 Modified 3/1/2012 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 has not acted in a way to cause disbarment (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).

image1.png