s SDQA - 417
Raleigh Facility Rev 1- 2/02
Annual
Business Certification
Date: ______
TO:Siemens Power Transmission & Distribution
P.O. Box 29503
Raleigh, NC 27626-0503
FROM:______
ADDRESS:______
CityCountyStateZip
The Offeror represents and certifies
- Type of Business Organization
The Offeror operates as ______an individual, ______a partnership, _____ a non-profit organization, _____ a corporation, incorporated under the laws of the state of ______.
2. Affiliation
The Offeror _____ is, or _____ is not, owned or controlled by a parent company. A parent company for the purpose of this certification is defined as a company, which either owns or controls the activities and basic business policies of the Offeror. To own another company means the parent company must own more than 50 percent of the voting rights in that company. To control another company, such ownership is not required. If another company is able to formulate, determine, or veto basic business policy decisions of the Offeror, such other company is considered the parent company of the Offeror. This control may be exercised through the use of dominant minority voting rights, use of proxy voting, contractual arrangements or otherwise.
If the Offeror is owned or controlled by a parent company, enter in the space below the name and complete main office mailing address of the parent company:
Company Name
Street Address
StateZip Code
- Business Classification Certification
The Offeror certifies that it is:
- _____ a large business concern
- _____ a large / women-owned business concern
- _____ a small business concern
- _____ a small / disadvantaged business concern
- _____ a small / women-owned business concern
- _____ a small / disadvantaged / women-owned business concern
Note:For the purpose of this certification the following definitions shall be used:
- Small business concern shall mean a small business as defined pursuant to Section 3 of the Small Business Act and relevant regulations.
- Small / disadvantaged business concern shall mean a small business concern which is at least 51 percent owned by one or more socially and economically disadvantaged individuals; or in the case of a publicly owned business, at least 51 percent of stock of which is owned by one or more socially or economically disadvantaged individuals; and whose management and daily business operations are controlled by one or more of such individuals.
- Socially and economically disadvantaged individuals shall include Black Americans, Hispanic Americans, Native Americans (American Indians, Eskimos, Aleuts and Native Hawaiians), Asian-Pacific Americans (U. S. citizens whose origin are from Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U. S. Trust-Taiwan), and other Minorities or any other individual found to be disadvantaged by the Small Business Administration pursuant to Section 6 (a) of the Small Business Act.
- Women-owned business concerns shall mean a business which is at least 51 percent owned by a woman or women who also control and operate it. “Control” is this context means exercising the power to make policy decisions. “Operate” is defined as actively involved in the day-to-day management. “Women” means all women business owners.
- Regular Dealer-Manufacturer
The Offeror is a _____ regular dealer in, or _____ manufacturer of the supplies offered. Materials and services provided by the Offeror are limited to______
______
- Company Certification
The official signing this form certifies that he is acting within the scope of his authority to make such representations and certifications and that the information furnished herein is current, complete and accurate as of the date of signing.
FIRM:______
NAME:______
TITLE:______
DATE:______
(Date of execution)
In the event any of the foregoing information changes, the Offeror must notify Siemens PT&D within twenty (20) calendar days of such change(s) taking place.
When complete please fax to Siemens PT&D, Attention Purchasing Department at (601) 939-3606.