Name: TIN: ► SECTION 1 - FEDERAL INFORMATION - REQUIRED What is the Federal classification type of your business? - See definitions on link below. (S.B.A. Small Business definition FAR 19.001 and size standards FAR 19.102) LARGE Business? YES NO SMALL Business? YES NO Please check all that apply to your business for Federal Supplier Type: Service Disabled Veteran Owned Small Disadvantaged (SD) Women Owned (WO) (VD) Veteran Owned (VO) Minority Institution (MI) HUB Zone (HZ) SECTION 2 - OF ARIZONA SMALL BUSINESS INFORMATION - REQUIRED Are you self-certified according to this of Arizona definition? full-time employees or less OR $4 million in volume or less in the YES NO “100 last fiscal year” Per FAR 52.219-1 and under 15 U.S.C. 645(d), any person who misrepresents a firm’s status as a small, HUB Zone small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references section 8(d) for a definition of program eligibility, shall be punished by imposition of fine, imprisonment, or both; be subject to administrative remedies, including suspension and debarment; and be ineligible for participation in programs conducted under the authority of the Act. Print Name: Signature: PHONE: FAX: VENDOR LIST – PRODUCT or SERVICE PROVIDED Phone: Fax: IF NAME IS LISTED PLEASE RETURN TO BUYER NOTE: IF BOTH PAGES OF THIS FORM ARE NOT COMPLETED THE FORM WILL BE RETURNED TO YOU. Arizona State University (ASU) is fulfilling a mandate associated with state agencies increasing procurements from Arizona Small and Diverse Businesses. APPENDIX 1 - RFP The following documents are required for this proposal (please mark off each document to acknowledge that you have submitted the document in the proper format): RFP Cover Page & Checklist, Mandatory Section 1 Certifications and Substitute W-9
► Name: TIN: SECTION 1 - FEDERAL INFORMATION - REQUIRED What is the Federal classification type of your business? - See definitions on link below. (S.B.A. Small Business definition FAR 19.001 and size standards FAR 19.102) LARGE Business? YES NO SMALL Business? YES NO Please check all that apply to your business for Federal Supplier Type: Service Disabled Veteran Owned (VD) Small Disadvantaged (SD) Women Owned (WO) Veteran Owned (VO) Minority Institution (MI) HUB Zone (HZ) SECTION 2 - OF ARIZONA SMALL BUSINESS INFORMATION - REQUIRED Are you self-certified according to this of Arizona definition? “100 full-time employees or less OR $4 million in volume or less in the last fiscal year” YES NO Per FAR 52.219-1 and under 15 U.S.C. 645(d), any person who misrepresents a firm’s status as a small, HUB Zone small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references section 8(d) for a definition of program eligibility, shall be punished by imposition of fine, imprisonment, or both; be subject to administrative remedies, including suspension and debarment; and be ineligible for participation in programs conducted under the authority of the Act. Print Name: Signature: PHONE: FAX: VENDOR – LIST PRODUCT or SERVICE PROVIDED IF NAME IS LISTED PLEASE RETURN TO BUYER Phone: Fax: NOTE: IF BOTH PAGES OF THIS FORM ARE NOT COMPLETED THE FORM WILL BE RETURNED TO YOU. Arizona State University (ASU) is fulfilling a mandate associated with state agencies increasing procurements from Arizona Small and Diverse Businesses. APPENDIX 1 - RFP The following documents are required for this proposal (please mark off each document to acknowledge that you have submitted the document in the proper format): Section 1 RFP Cover Page & Checklist, Mandatory Certifications and Substitute W-9
RFP021306_PublicPrograms_DecisionTheater_2.6.13.docx