Contractor_Information_Sheet_-_Monrovia.docx

Contractor/Vendor Information Sheet

Please fill in all information below, type or print information clearly. Please complete the following questions and return to Rachel Cook (CookR1@state.gov) by 7 November 2016 at 16:00 EST.

Legal Business Name:

Tax ID No: DUNS No:

Mailing Address:

City, State, Zip Code:

Country:

Toll Free Number: Website Address:

Point of Contact:

Phone Number: Fax:

E-mail Address:

Country of Origin U.S. Firm ___ Foreign Vendor ___ Country: ___________

Size of Business:

Large ___ Small ___

Corporate Status:

Corporation ___ S-Corporation ___ Sole Proprietorship ___ Partnership ___ Other: _______________

Type of Ownership:

Woman ___ Veteran-owned___ (Service-disabled ____) Minority___ None of the Above ___ Other: _________________

Socio-Economic Status:

8(a) Status ___ HUBZone___ Disadvantaged____ None of the Above ___ Other:_________________

Registered in SAM: Yes No _

DCAA-approved accounting practices: Yes No _

Do you currently do business in Liberia? Yes____ No____

Have you performed guard services in Liberia under NAICS code 561612? Yes____ No____