VENDOR REGISTRATION AND DISCLOSURE STATEMENT AND SMALL, WOMEN-, AND MINORITY-OWNED BUSINESS CERTIFICATION APPLICATION

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1 WV-1A New Update REV. 09/18/15 STATE OF WEST VIRGINIA - PURCHASING DIVISION VENDOR REGISTRATION AND DISCLOSURE STATEMENT AND SMALL, WOMEN-, AND MINORITY-OWNED BUSINESS CERTIFICATION APPLICATION Befre a vendr is eligible t sell gds and/r services t the State f West Virginia, the West Virginia Cde 5A 3 12 requires all vendrs t have n file with the West Virginia Purchasing Divisin a cmpleted Vendr Registratin and Disclsure Statement. Vendrs supplying sle surce gds r services t West Virginia state agencies, r cmpetitive purchases f $2,500 r less annually in aggregate acrss all state agencies are required t cmplete the Vendr Registratin and Disclsure Statement (WV 1A frm). If the amunt fr cmpetitive purchases exceed $2,500 in aggregate acrss all state agencies in any ne year, a $ annual fee is required. Payment f the annual fee includes ntificatins n bid pprtunities based n the cmmdities and services selected upn registering in the Vendr Self Service (VSS) prtal at wvoasis.gv. Please cmplete Part I f this frm in its ENTIRETY and return t the state agency listed belw fr their cmpletin f Part II. The agency will frward this frm t the West Virginia Purchasing Divisin fr prcessing. Incmplete frms will nt be prcessed and will be returned t the vendr. Please return all crrespndence t: STATE AGENCY: ADDRESS: CITY, STATE, ZIP: Whenever a change ccurs in the infrmatin submitted, such change shall be reprted immediately in the same manner as required in the riginal disclsure statement (West Virginia Cde 5A 3 12). Vendrs ding business with the State f West Virginia are expected t abide by the Vendr Cde f Cnduct available nline at purchase/vrc/vendrcnduct.pdf. Privacy Ntice: The Purchasing Divisin is required t cllect certain infrmatin as stated in West Virginia Cde 5A 3 12, ther applicable sectins f the West Virginia Cde, the Vendr Registratin and Disclsure Statement frms, and ther dcuments t facilitate the state bidding and cntract administratin prcesses. This infrmatin is stred in a secure envirnment, but unless specifically prtected under state law, any infrmatin prvided may be inspected by r disclsed t the public. Vendrs are als required t be licensed and in gd standing in accrdance with any and all state and lcal laws and requirements by any state r lcal agency f West Virginia, including, but nt limited t, the West Virginia Secretary f State s Office, the West Virginia Tax Department, West Virginia Insurance Cmmissin, r ther state agencies r plitical subdivisins. Failure t d s may result in delay f r disqualificatin frm a cntract award, pursuant t West Virginia Cde f State Rules If yu have any questins cncerning this Vendr Registratin and Disclsure Statement, please cntact the Purchasing Divisin at (304) Questins cncerning this Vendr Registratin and Disclsure Statement may be directed t the Purchasing Divisin at (304) Shuld yu need additinal infrmatin relating t vendr registratin, please visit WV 1A Revised 09/18/15 Page 1

2 1. Legal Name f Cmpany/Individual Bidding Address Ordering Address Payment Address City, State, Zip Telephne Number Principle Cntact Persn Cntact s Telephne Number Fax Number E mail Cntact s Fax Number DBA, if any Bidding Address Ordering Address Payment Address City, State, Zip Telephne Number Principle Cntact Persn Cntact s Telephne Number Fax Number E mail Cntact s Fax Number 2. Vendr Tax Classificatin: Individual Gvernment Sle Prprietr Medical Crpratin Partnership Attrney Crpratin Crpratin Nn Prfit Organizatin Bard Member Payrll Trust Emplyee Estate WV 1A Revised 09/18/15 Page 2

3 3. Taxpayer Identificatin Number (TIN): If yu have an Identificatin Number, enter it belw. All partnerships, crpratins, r cmpanies with emplyees must have an EIN. EIN If yu d nt have a EIN, please enter Scial Security number (SSN), Individual Taxpayer Identificatin Number (ITIN) r Adptive Identificatin Number (ATIN) and check the crrect belw. - (SSN G, ITIN G, ATIN G) 4. (A) Small, Wmen Owned, Minrity Owned Businesses West Virginia Cde 5A 3 59 establishes a prcurement certificatin prgram in West Virginia fr small, wmen, and minrity wned businesses. Requirements related t the certificatin prgram are prvided in the West Virginia Cde f State Rules et seq. Nte that this certificatin prvides nnresident vendrs preference that is equivalent t cmpeting resident (West Virginia) vendrs that have applied fr resident vendr preference, in accrdance with West Virginia Cde 5A This certificatin may assist resident small, wmen, and minrity wned businesses when sliciting business in ther states. If yu are renewing yur tw year SWAM business certificatin status, please indicate the apprpriate designatin belw. Certificatin f Status (Check all thse which apply) Minrity wned Business [1] means a business cncern that is at least fifty ne percent wned by ne r mre minrity individuals r in the case f a crpratin, partnership, r limited liability cmpany r ther entity, at least fifty ne percent f the equity wnership interest in the crpratin, partnership, r limited liability cmpany r ther entity is wned by ne r mre minrity individuals and bth the management and daily business peratins are cntrlled by ne r mre minrity individuals. A minrity individual means an individual wh is a citizen f the United States r a nncitizen wh is in full cmpliance with United States immigratin law and wh satisfies ne r mre f the fllwing definitins: African American means a persn having rigins in any f the riginal peples f Africa and wh is regarded as such by the cmmunity f which this persn claims t be a part. Asian American means a persn having rigins in any f the riginal peples f the Far East, Sutheast Asia, the Indian subcntinent r the Pacific Islands, including, but nt limited t, Japan, China, Vietnam, Sama, Las, Cambdia, Taiwan, Nrthern Mariana, the Philippines, a U.S. territry f the Pacific, India, Pakistan, Bangladesh, r Sri Lanka and wh is regarded as such by the cmmunity f which this persn claims t be a part. Hispanic American means a persn having rigins in any f the Spanish speaking peples f Mexic, Suth r Central America, r the Caribbean Islands r ther Spanish r Prtuguese cultures and wh is regarded as such by the cmmunity f which this persn claims t be a part. Native American means a persn having rigins in any f the riginal peples f Nrth America and wh is regarded as such by the cmmunity f which this persn claims t be a part r wh is recgnized by a tribal rganizatin. WV 1A Revised 09/18/15 Page 3

4 Small Business [2] means a business, independently wned r perated by ne r mre persns wh are citizens f the United States r nncitizens wh are in full cmpliance with United States immigratin law, which, tgether with affiliates, has tw hundred fifty r fewer emplyees, r average annual grss receipts f $10 millin r less averaged ver the previus three years. Wmen wned Business [3] means a business cncern that is at least fifty ne percent wned by ne r mre wmen wh are citizens f the United States r nncitizens wh are in full cmpliance with United States immigratin law, r in the case f a crpratin, partnership r limited liability cmpany r ther entity, at least fifty ne percent f the equity wnership interest is wned by ne r mre wmen wh are citizens f the United States r nncitizens wh are in full cmpliance with United States immigratin law, and bth the management and daily business peratins are cntrlled by ne r mre wmen wh are citizens f the United States r nncitizens wh are in full cmpliance with United States immigratin law. (B) Other Federal Designatins Additinally, by prviding the fllwing infrmatin, I represent that this enterprise is a small business as defined by the Cde f Federal Regulatins, Title 13, Part 121, as appended which cntains detailed industry definitins and related prcedures and/r the characteristics f the enterprise's cntrl, peratin and/r wnership are accurately reflected in the infrmatin prvided. Check all that apply. Disabled Small Business Ownership [4] Veteran Small Business Ownership [5] 5. Cmmdity Cdes: Yu may register fr cmmdity cdes fr the prducts and services that yu ffer, which will prvide yu with bid pprtunity alerts and ntificatins shuld yu becme a paid registered vendr. T perfrm this functin, visit the Vendr Self Service (VSS) prtal at wvoasis.gv. 6. List the name, title, city and state f residence fr all wners/fficers. If the vendr is an individual, list his r her name and city and state f residence, and, if he r she has assciates r partners sharing in his r her business, list their names and city and state f residence. If the vendr is a firm, list the name and city and state f residence f each member, partner r assciate f the firm. If the vendr is a crpratin created under the laws f this state r authrized t d business in this state, list the names and city and state f residence f the president, vice president, secretary, treasurer and general manager, if any, f the crpratin; and the names and city and state f residence f each stckhlder f the crpratin wning r hlding at least ten percent f the capital stck theref. Attach an additinal sheet if space is needed. Name Psitin City and State f Residence If the vendr has nly ne wner/fficer, list the name, psitin, and city and state f residence abve and please initial here: WV 1A Revised 09/18/15 Page 4

5 7. List the name and telephne number f ne r mre banking institutins t serve as reference fr the vendr. 8. What is the latest Dun & Bradstreet number and rating n the vendr? 9. Is the vendr acting as an agent fr sme ther individual, firm r crpratin? If yes, attach statement f the principal authrizing such representatin. N Yes By signing belw and submitting this frm, the vendr certifies and acknwledges that: 1) it has btained all licenses, certificatins, and authrizatins necessary t lawfully cnduct business in the state f West Virginia; and 2) that the assertins made by cmpleting this frm and delivering it t the Purchasing Divisin are accurate and true in accrdance with the applicable law and rules. As authrized agent f the vendr named herein, I d slemnly swear that the abve infrmatin is true and cmplete, in accrdance with West Virginia Cde 5A 3 12(e). In the event that the vendr is applying fr certificatin as a small, wmen, r minrity wned business, the vendr s signature belw further certifies that: 1) the state in which the vendr has its headquarters r principal place f business des nt deny a like certificatin t a West Virginia based small, wmen wned, r minrity wned business; 2) the state in which the vendr has its headquarters r principal place f business des nt prvide a preference t small, wmen wned, r minrity wned firms that is unavailable t West Virginia based businesses; and, 3) that it has read and understands this frm, alng with the law and rules gverning certificatin as a small, wmen wned, r minritywned business. Authrized Agent f Vendr (Print Name) Authrized Agent (Signature) Title Date PURCHASING DIVISION USE ONLY Vendr ID: Check N. : Mem N. : Date: Entered by: WV 1A Revised 09/18/15 Page 5

6 Part II: FOR STATE USE ONLY T Be Cmpleted by State Agency and Returned t Purchasing Divisin 1. Please prvide a cncise descriptin f the gds and/r services the vendr is prviding with yur specific transactin. 2. Cite the crrespnding exemptin cde frm Sectin 9 f the Purchasing Divisin Prcedures Handbk, if applicable. 3. Are the gds and/r services cnsidered sle surce? N Yes 4. Will the gds and/r services prvided by this vendr exceed $2,500 in aggregate acrss all state agencies? If nt, and an award under this dllar threshld is pending, please als cntact the wvoasis Finance Team at fr a prcessing cde t use n yur wvoasis award dcument. N Yes State Agency Prcurement Officer Signature Telephne N. Date FAX N. Return t: WV Purchasing Divisin Vendr Registratin 2019 Washingtn Street, East Charlestn, WV WV 1A Revised 09/18/15 Page 6

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