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Business Size Large BusinessSmall BusinessSmall Disadvantaged BusinessMinority Owned Business (Certified? please attach verification)Woman Owned Business (Certified? please attach verification)Veteran Owned Business (Gov’t registration/certification required)Service Disabled Veteran Owned Business Gov’t Reg’n/ Cert’n required)8(a) 8(a) (Certificate from Small Business Administration must be submitted with this form.)HUBZone (Certificate from Small Business Administration must be submitted with this form.) A for-profit enterprise located in a historically underutilized business zone and at least 35% of employees reside in a HUBZoneHistorically Black College/University or Minority InstitutionOther: Specify (If other business type, please specify)
If minority owned, please select African-AmHispanic AmAsian-Indian AmNative AmAsian-Pacific AmOther
If minority, CERTIFIED BY AN INDEPENDENT 3RD PARTY? YesNo
A U.S.-based for-profit enterprise (size independent) with at least 51% ownership and controlled by one or more US Citizen women. CERTIFIED BY AN INDEPENDENT 3RD PARTY? YesNo
A U.S.-based for-profit enterprise (size independent) with at least 51% ownership and controlled by one or more US Citizens who are veterans of the U.S. Armed Forces. CERTIFIED BY AN INDEPENDENT 3RD PART YesNo
A U.S.-based for-profit enterprise (size independent) with at least 51% ownership and controlled by one or more disabled veterans. CERTIFIED BY AN INDEPENDENT 3RD PARTY? YesNo
If HUBZone, please select one Federal HUBZone CertifiedState HUBZone Certified
Primary Contact
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Supplier Classification (Check all that apply and confirm certification status.) Unless otherwise noted, please use the definition for the below categories in the Federal Acquisition Regulation 19.7 or 52.219-8.
The undersigned acknowledges and affirms that the information given on this form is true, complete and correct and that he/she is qualified and authorized to make these representations on behalf of the undersigned Company. The undersigned further affirms that the Company is responsible for notifying Owens & Minor Supplier Diversity Director immediately in writing if the Company size, ownership status or other relevant information changes. It is the responsibility of the Company to maintain or update any applicable diversity classification(s) through a 3rd party certifying authority. By completing this Certification, there is no written or implied representation that the Supplier shall be selected to perform services or provide materials to Owens & Minor.
Comments
Under 15 U.S.C. 645(d), any company 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.