| Company Name: |
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| Business Owner(s): |
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| Contact Name: |
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| Title: |
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Physical Address
(City/State/Zip)
: |
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Mailing Address
(if different than Physical Address): |
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| City: |
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| State: |
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| Zip: |
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| County: |
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| Work Phone: |
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| Cell Phone: |
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| E-mail: |
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| Fax: |
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| Website: |
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Indicate Tribal Heritage
of Owner(s): |
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Is this business located
on or near a reservation?
|
Yes No |
Type of Tribal
Recognition: |
Federal
State
NAI Organization
Self-Certified |
 |
General Information: |
| DUNS Number: |
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| CAGE Code: |
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| Number of Employees: |
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| CCR Registered? |
Yes No
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| Type of Organization: |
Individual
Limited Liability
Partnership
Tribally-Owned
Corporation Incorporated in the State of:
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Business Size:
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Small Business Other Than Small Business |
Type of Ownership
(Check all that apply): |
|
Certifications
(Check all that apply): |
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Check one category that
best describes your business: |
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| Where do you do Business? |
Local
Nationwide
International
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| List Specific State(s) or countries: |
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Provide a brief description
of your business: |
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List any information about
your company that you would
want a potential customer to know: |
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List NAICS, FSC, PSC Codes applicable
to your business: |
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List any KEY WORDS (phrases,
acronyms, part numbers, etc.) pertinent to your business.
This will
assist with
appropriate Bid Matches.
Example: (Client: XYZ Office Supply
Company, Common Key words: "Office Supplies" "paper printing binding"
"office furniture") |
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By submitting this form, you are agreeing to the following:
- Assistance Request: I request procurement and technical assistance services for doing business with the Federal, State or Local government from UIDA Business Services. I agree to participate in a brief annual survey designed to evaluate UIDA Business Services. I authorize UIDA Business Services to furnish relevant information to the assigned specialist and understand this information will be held in the strictest confidence.
- Reporting Agreement: I agree to complete and submit the Quarterly Contract Report form indicating any contracts, new or existing, that my company receives as a client of UIDA. I agree to submit reports in the allotted timeframe and understand if the reports are not received, UIDA reserves the right to interrupt services until the report is received. I also understand that if the Quarterly Contract Reports are not received for two consecutive periods, UIDA reserves the right to change my status from an Active Client to an Inactive Client. This information is to be treated as confidential.
- The Reporting Agreement form can be completed on line, mailed, or faxed. The information obtained from this form is used by our funding sources to evaluate and measure the success of small businesses in government contracting. We are required to substantiate each contract(s) award you report. Accordingly, you may be asked to send a copy of the face page of the contract(s) which reflects purchasing agency name, contract or purchase order number, and dollar amount of award.
I further understand that all UIDA Business Services Specialists have agreed not to: (1) recommend goods or services from sources in which he/she has an interest and (2) accept fees or commissions from this relationship. In consideration of UIDA Business Services furnishing technical assistance, I waive all claims against UIDA personnel and its host organizations arising from this assistance. |
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