**SUPPLIER REPRESENTATIONS/CERTIFICATIONS**

**FOR THE**

**ACQUISITION OF GOODS AND SERVICES \<\$100,000**

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

From:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Company

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Street Address/P.O. Box

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City/State/Zip Code

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-Mail Address

Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Fax: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1.  Cash Terms:

> (\_) Prompt Payment Discount: \_\_\_\_% for Payment within \_\_\_\_
> Days
>
> (\_) No Prompt Payment Discount: Net 30 Days

2.  Business Type Certification:

> (\_) Corporation (\_) Partnership
>
> (\_) Individual (\_) Sole Proprietorship
>
> State: \_\_\_\_\_\_\_\_\_\_\_
>
> (\_) Non-resident foreign individual, foreign partnership, foreign
> corporation, or foreign non-profit entity
>
> If Offeror certifies its business type to be \"Individual\",
> \"Offeror\" further certifies that Offeror \[(\_) is (\_) is not\] a
> participant in an INL Retirement Plan.

3.  As currently defined by the Small Business Administration, Offeror
    certifies it:

(\_) is a small: *Select applicable small business classification(s):*

> (\_) Native American Business
>
> (\_) Woman-Owned Business
>
> (\_) Disadvantaged \[(\_) 8(a) (\_) non 8(a)\] Business
>
> (\_) HUB Zone Business
>
> (\_) Veteran Owned \[(\_) Service Disabled\]
>
> (\_) None of the Above

(\_) is a large business (\_) is a sheltered workshop

(\_) is a non-profit business (\_) is an educational institution

North American Industrial Classification System (NAICS) No.:
\_\_\_\_\_\_\_\_\_\_\_\_\_

Size Standard:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4.  Any facility to be utilized in the performance of the proposed
    subcontract \[(\_) has (\_) has not\], been listed on the
    Environmental Protection Agency (EPA) List of Violating Facilities.
    Offeror will promptly notify Contractor, prior to award, of the
    receipt of any communication from the Director, Office of Federal
    Activities, EPA, indicating that any facility it proposes to use for
    the performance of the subcontract is under consideration to be on
    the EPA List of Violating Facilities. Offerors will include
    substantially this certification, including this sentence, in every
    nonexempt lower-tier subcontract.

5.  DUNS Number:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Federal Tax ID or SS#:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Principal Place of Performance:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6.  The Offeror \[(\_) is (\_) is not\] a parent, division, subsidiary
    or affiliated or associated company of Battelle. If the Offeror is,
    complete the following:

> [Parent Company]{.underline} [Address]{.underline}
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7.  The Offeror or its principals certify it \[(\_) does not (\_) does\]
    appear on the GSA List of Parties Excluded From Federal Procurement
    or Nonprocurement Programs and \[(\_) is not (\_) is\] proposed for
    debarment by the Federal Government.

8.  The Offeror certifies that the following line item(s) is/are
    [Domestic]{.underline} as defined under the Buy American Act:

\[(\_) All (­\_) None (\_)
Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\]

(*insert **[Nondomestic]{.underline}** line item no(s) only*.)

9.  [Certification of Nonsegregated Facilities]{.underline} (Applicable
    to acquisitions of \$10,000 or more):

    1.  Segregated facilities, as used in this provision, means waiting
        rooms, work areas, rest rooms and wash rooms, restaurants and
        other eating areas, time clocks, locker rooms and other storage
        or dressing areas, parking lots, drinking fountains, recreation
        or entertainment areas, transportation, and housing facilities
        provided for employees, that are segregated by explicit or
        directive or are in fact segregated on the basis of race, color,
        religion, or national origin because of habit, local custom, or
        otherwise.

    2.  By submission of this offer, the Offeror certifies that it does
        not and will not maintain or provide for its employees any
        segregated facilities at any of its establishments, and that it
        will not permit its employees to perform their services at any
        location under its control where segregated facilities are
        maintained. The Offeror agrees that a breach of this
        certification is a violation of the Equal Opportunity clause in
        the Purchase Order.

    3.  The Offeror further agrees that (except where it has obtained
        identical certifications from proposed lower-tier subcontractors
        for specific time periods) it will:

        1.  Obtain identical certifications from proposed lower-tier
            subcontractors before the award of subcontractors under
            which the subcontractors will be subject to the Equal
            Opportunity clause:

        2.  Retain the certification on file; and

        3.  Forward the following notice to the proposed lower-tier
            subcontractors (except if the proposed subcontractors have
            submitted identical certifications for specific time
            periods):

NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR CERTIFICATIONS
OF NONSEGREGATED FACILITIES.

A Certification of Nonsegregated Facilities must be submitted before the
award of a subcontract under which the subcontractor will be subject to
the Equal Opportunity clause. The certification may be submitted either
for each subcontract or for all subcontracts during a period (i.e.,
quarterly, semiannually, or annually).

10. [F.O.B./Transportation Terms]{.underline}

> \*FOB: (\_) Destination or (\_) Origin
>
> \*Trans. Terms: (\_) Freight Allowed or (\_) Freight Not Allowed
>
> *\*Note:*

1\. \"Destination\" means Supplier owns goods in transit; \"Origin\"
means Contractor owns goods in transit.

2\. \"Freight Allowed\" means Supplier bears freight; \"Freight Not
Allowed\" means Contractor bears freight.

11. [Terms and Conditions]{.underline}: The Offeror accepts Form
    PROC-202, General Provisions for Commercial Items/Services, dated
    06/06 (including future revisions) and Form PROC-182c, Software
    License, dated 04/03 (including future revisions) as applicable to
    all Purchase Orders \<\$100,000 for commercial goods, except those
    involving a written Request for Proposal, or those issued under GSA
    terms and conditions.

The Offeror agrees that the representations and certifications
designated herein will remain in effect on all Purchase Orders for
commercial goods valued \<\$100,000 from the Prime Contractor, except
those involving a written Request for Proposal, for one year from the
date of signature. Additionally, the Offeror agrees to update any
information contained herein which changes for one year from the date of
signature.

Offeror\'s Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Offeror\'s Printed Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_