PR-FRM-22 SUPPLIER INFO BUS DEC FRM.doc

SUPPLIER INFORMATION AND BUSINESS DECLARATION FORM

It is the policy of ASRC Federal and its Subsidiaries that small businesses, small disadvantaged business concerns, woman-owned small businesses and HUBZone, veteran and service disabled veterans small businesses concerns, have the maximum practicable opportunity to participate in the performance of contracts awarded by ASRC. In order to comply with this policy, please provide the following information and a copy of your W-9.

(All information on this form is required)

*Supplier's Name

No. of Employees

*Street Address *Phone Number

Fax Number

*City *State *Zip

*Email Address

Remittance Street Address (* if different from Above)

City State Zip

*DUNS # *Federal Tax ID No. (EID) *Cage Code *Common parent.

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* Supplier is not owned or controlled by a common parent as defined in paragraph (a) of this provision.

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*Name and TIN of common parent:

*Name

*TIN

*This company is (check the ones that apply):

A Division of:

A Subsidiary of:

An Affiliate of:

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Individual

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Partnership

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Independently Owned and Operated

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Consultant

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Distributor

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Retailer

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Manufacturer

Corporation, incorporated under the laws of the state:

Foreign Owned (non USA)

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Non-Profit

1099 Required:

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Yes

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No

Other

*Identify Major Supplies/Services Primary North American Industry Classification System (NAICS) Codes NAICS:

*Business Size/Type (select one only):

Small Business

Large Business

*(Block 1) Business Ownership (select the ones that apply):

Minority

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SBA Certified Disadvantaged

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Women-Owned Business

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Historically Black College/Minority Institute

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Service Disabled Veteran owned

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HUB Zone (Certified by SBA)

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Veteran Owned

(Block 2) If Minority/Disadvantaged is selected above, please check the appropriate category in which business ownership falls:

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African American

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Asian Pacific American

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Hispanic American FORMCHECKBOX Native American

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Subcontinent Asian American

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Alaska Native Corp (ANC) FORMCHECKBOX Other than those listed

Authorized Signature

Title

Printed Name

Date

ASRC Federal and its Subsidiaries (ASRC) may award procurement to the seller where the costs will be charged to a U.S. government prime or subcontract. If so, the seller is advised that the U.S. government may impose a penalty against a firm misrepresenting its business size and/or disadvantaged status for the purposes of obtaining procurement that is to be included as part, or all of a goal contained in ASRC’s Subcontracting plan. Eligibility as a small business is based on the regulations issued by the Small Business Administration in CFR 13, Part 121 of the SBA Rules and Regulations and FAR 52.219-1.

PR-FRM-22 Rev. 03 03/9/18