The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding Signature of U.S. Individual Date: 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. ARIZONA STATE UNIVERSITY DO NOT SEND RETURN TO TO IRS SUBSTITUTE W-9 & VENDOR AUTHORIZATION FORM Page 2 of 2 – ASU Legal 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 - STATE OF ARIZONA SMALL BUSINESS INFORMATION - REQUIRED Are you self-certified according to this State of Arizona definition? employees or less OR $4 million in volume or less in the YES NO “100 full-time last fiscal year” Per FAR 52.219-1 and under 15 U.S.C. 645(d), any person who misrepresents a status as a small, HUB Zone firm’s 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 Buyer: Phone: Fax: IF BUYER NAME IS
The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding Signature of U.S. Individual Date: 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. RETURN TO ASU ARIZONA STATE UNIVERSITY SUBSTITUTE W-9 & VENDOR AUTHORIZATION FORM – Page 2 of 2 DO NOT SEND TO IRS ► Legal 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 - STATE OF ARIZONA SMALL BUSINESS INFORMATION - REQUIRED Are you self-certified according to this State 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 BUYER NAME IS Buyer: Phone: Fax:
221403ContactCenterInfrastructreSolutionforASU.docx