TO:
/
Vendor:
Attn:
Fax #:
/
() -

We ask that all Vendors take a few minutes to fill out the attached Vendor Business Profile Questionnaire to assist us in determining and monitoring procurement activities and classifications. This information is necessary for Seeds Of Change to issue purchase orders and pay invoices.

Government Regulations

(1)Whoever misrepresents the status of any concern or person as a "small business concern" or "small business concern owned and controlled by socially and economically disadvantaged individuals or HUBZone classification", in order to obtain for oneself or another any-- (A) prime contract to be awarded pursuant to section 638 or 644 of this title; (B) subcontract to be awarded pursuant to section 637(a) of this title; (C) subcontract that is to be included as part or all of a goal contained in a subcontracting plan required pursuant to section 637(d) of this title; or (D) prime or subcontract to be awarded as a result, or in furtherance, of any other provision of Federal law that specifically references section 637(d) of this title; for a definition of program eligibility, shall be subject to the penalties and remedies described in paragraph (2).

(2) Any person who violates paragraph (1) shall--- (A) be punished by a fine of not more than $500,000 or by imprisonment for not more than 10 years, or both; (B) be subject to the administrative remedies prescribed by the Program Fraud Civil Remedies Act of 1986 (31 U.S.C.3801-3812); (C) be subject to suspension and debarment as specified in subpart 9.4 of title 48, Code of Federal Regulations (or any successor regulation) on the basis that such representation indicates a lack of business integrity that seriously and directly affects the present responsibility to perform any contract awarded by the Federal Government or a subcontract under such a contract; and (D) be ineligible for participation in any program or activity conducted under the authority of this chapter or the Small Business Investment Act of 1958 (15 U.S.C. 661 et seq.) for a period not to exceed 3 years.

Comments

MNM-E2138 (Rev 4/06)

Vendor Business Profile

(Please type or print legibly)

Internal Use Only – To be completed by Commercial Buyer or requestor
Is this a current supplier/vendor? No Yes (if yes, please provide Vendor number) Vendor Number
Company Name
(order from information)
Address
City/State/Zip
Telephone No. / () - / Fax Number / () -
Contact / Title
Type of Business / Billing Terms
Tax Identification Number / Social Security Number
(For individuals and sole proprietors) / --
Name As Shown On Social Security Card
Remit to Address Company Name
(if different)
Address
(as it appears on invoice)
City/State/Zip
Telephone No. / () - / Fax Number / () -
Dun’s No. / FOB / Freight Payment
Are you a US Citizen or Resident Alien? Yes No

In accordance with government regulations and prime contract requirements, we are required to verify the business size and classification of our current suppliers and potential suppliers. All small business concerns may wish to review the definitions pertaining to small businesses under Federal Acquisition Regulations 19.7or 52.219-8 ( Under 15 U.S.C. 645(d), any person who misrepresents its size status shall (1) be punished by 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. For additional assistance, contact SBA at 1.800.U.ASK.SBA or refer to SBA's website at or Central Contractor Registration at

BUSINESS CLASSIFICATION: Check all Applicable Box(es) / BUSINESS ORGANIZATION:
Large Business Concern (Non-Minority) / Individual/Sole Proprietor / Partnership or LLC
Small Business Concern (Non-Minority) / Manufacturer / Service Organization
Small Disadvantaged Business Concern / Corporation
(proof of certification is required) / INDUSTRIAL TYPE CODES
Women-Owned Small Business 9u / Raw Materials / Technical/MRO / Packs Materials
Substitute Payments (dividends/interest) / IT / Logistics / Services
Service Disabled Veteran-Owned Small Business / Royalties / Media / Rents
Large Business Minority-Owned Concern / Federal Income Tax Withheld / Other Income
Large Business Women-Owned Concern / Non-Employee Compensation / Medical & Health Care
HUBZone Small Business (proof of certification is required) / Substitute Payments / Payments
Non-Profit Organization / (dividends/interest) / Payer Made Direct Sales
US/State Government / State Income Tax Withheld / of $5000 or more
Foreign Vendor / Gross Proceeds Paid To An
Other Minority Business Concerns: / Attorney
Black Asian Indian Asian Pacific Hispanic American Native American

The undersigned hereby certifies that the information provided herein is current, complete, and accurate as of this date. If Business Classification checked indicates a minority-owned or woman-owned business concern, the undersigned also certifies that this company is at least 51% owned and controlled by minority individuals or women. Refer to the National Minority Supplier Development Council (NMSDC) at or the Women's Business Enterprise National Council (WBENC) @ for assistance with certification. NOTE: Valid copies of all applicable certificates are required with submission of completed Vendor Business Profile.

1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2.I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends; or (c) the IIRS has notified me that I am no longer subject to backup withholding.

CERTIFICATION INSTRUCTIONS: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividens, you are not required to sign the Certification, but you must provide your correct TIN.

CERTIFIED BY: / (signature)
NAME(Type or Print): / TITLE:
PURCHASE ORDER E-MAIL ADDRESS (Type or Print):
DATE:
WHAT IS THE PREFERRED METHOD TO RECEIVE PO’s / FAX / or / E-Mail
Please Return Profile To: / Requester:
Fax Number: / () -
Add To Database: / Mailing Address:
Date Submitted:
To receive EFT (Electronic Funds Transfer) / Check / Yes / No / Paperwork will then be sent.

MNM-E2138 (Rev 4/06)