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.

Signature and Affidavit

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.

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.