vendor questionairre.docx

VENDOR QUESTIONNAIRE

Email Address

ATTN: To whom it may concern:

Completion of this form and W-9 is required in order for your business to receive full payment for goods and services. If you are a small business, please read the attached small business certification and check the appropriate designation(s) below.

Type of Service Provided: _______________________________________________________

Company Name: ______________________________________________________________

Street Address: _______________________________________________________________

City: _____________________________ State & Zip: ___________________________

Remittance Address (if different): _______________________________________________

City: __________________________ State & Zip: ______________________

Telephone #: _________________________ Fax #: _________________________

Check all Categories that Apply:

|_| 1. Small Business |_| 2. Small Disadvantaged Business (8a Must be SBA Certified)*

NOTE:

This certification is valid unless you notify us of any changes. It is your responsibility to notify us if your size or ownership status changes.

)|_| 3. Women Owned Small Business |_| 4. HUBZone Small Business (Must be SBA Certified)* |_| 5. Veteran Owned Small Business |_| 6. Service-Disabled Veteran Owned Small Business |_| 7. Historically Black College/University or Minority Institution |_| 8. Large Business |_| 9. Government |_| 10. Non-Profit *Primary NAICS Code (for SBA Certified business): _________________________

SMALL AND SMALL DISADVANTAGED BUSINESS CERTIFICATION

Adams and Associates, Inc. participates in the Government’s Small and Small Disadvantaged Business programs. This requires written certification from our suppliers and contractors as to their business status. Please furnish the information requested below.

(1) Which is at least 51% owned by one or more socially and economically disadvantaged individuals; or in the case of any publicly owned business, at least 51% of the stock of which is owned by one or more socially and economically disadvantaged individuals and

(2) Whose management of daily operations is controlled by one or more such individuals. The contractor shall presume Black Americans, Hispanic Americans, Native Americans (such as American Indians, Eskimos, Aleuts and Native Hawaiians), Asian-Pacific Americans and other minorities or any other individual found to be disadvantaged by the Administration pursuant to Section 8 (a) of the Small Business Act and

(3) If the Vendor is an 8(a) business, it must be certified by the SBA as a Small Disadvantaged Business. If not an 8(a) business, the Vendor may self-certify as a Small Disadvantaged Business if the above criteria are met.

Notice: In accordance with 15 U.S.C. 645(d)., any person who misrepresents a firm’s proper size classification shall (1) be punished by imposition of a fine, imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act.

If you have difficulty determining your size status, you may contact the Small Business Administration at 1-800-U-ASK-SBA OR 202-205-6618. You may also access the SBA website at www.sba.gov/size or you may contact the SBA Government Contracting Office at answerdesk@sba.gov or 817-827-5722. (Rev.10/2011) image1.png