QUALIFIED SUPPLIER'S LIST APPLICATION 

QSLDIOSLM CATEGORY 1. TYPE OF □ QSLM □ OSLO □ REVISION 2. DATE

(FIBER ROPE.CORDAGE, APPLICATION

TWINE, AND TAPE) (CHECK AU. rHAr APPi.Yi □ INITIAL □ REAPPLICATION

NOTE: COMPLETE ALL rrEMS. INSERT N/A IN rrEMS NOT APPLICABLE. SEE REVERSE FOR APPLICABLE DEFINITIONS. 

PUBLIC REPORTIIIIG BURDEN FOR THIS COLLECTION OF INFORMATION IS ESTIMATED TO AVERAGE 1.0 HOURS PER RESPONSE. INCLUDING THE TIME FOR REVIEWING INSTRUCTIONS, SEARCHING 

EXISTING DATA SOURCES, GATHERING AND MAINTAINING THE DATA NEEDED, AND COMPLETING AND REVIEWING THE COLLECTION OF INFORMATION. INCLUDING SUGGESTIONS FOR REDUCING THIS 

BURDEN, TO THE FAR SECRETARIAT (VRS), OFFICE OF FEDERAL ACQUISITION POLICY, GSA, WASHINGTON, OC 2040S. 

3. SUBMIT FORM TO: 4. NAME AND ADDRESS OF APPLICANT !INCLUDE COUNTY & ZIP CODE)

CAGE IF APPLICANT DOES NOT HAVE A CAGE SEE 

CRITERIA 

5. TYPE OF ORGANIZATION (CHECK ONE) &. ADDRESS TO WHICH SOLICITATIONS ARE TD BE MAILED 

□ INDIVIDUAL □ NON-PROFIT ORGANIZATION ( IF DIFFERENT THAN ITEM 4 l 

□ PARTNERSHIP □ CORPORATION INCORPORATED

UNDER THE LAWS OF THE 

STATE OF: 

7. NAMES OF OFFICER, OWNERS. OR PARTNERS

A. PRESIDENT B. VICE PRESJDEIT I

C. SECRETARY

D. TREASURER £. OCIIGR!IMCL TEL) 

8. AFFILIATES OF APPLICANT (NAMES. LOCATION AND NATURE OF AFFILIATION. ATTACH SEPARATE SHEET IF NECESSARY)

9. PERSONS AUTHORIZED TO SIGN OFFERS AND CONTRACTS IN YOUR NAME ( INDICATE IF AGENT)

NAME OFFICIAL CAPACITY TELEPHONE NO. AND FAX NO. (Include area code) 

10. SIZE OF BUSINESS □ SMALL BUSINESS AVERAGE NUMBER OF EMPLOYEES (SEE DEFINITIONS ON PAGE 2)

(INCLUDING AFFILIATES FDR FOUR 

□ OTHER THAN PRECEDING CALENDAR QUARTERS) 

11. TYPE OF OWNERSHIP (SEE DEFINITIONS ON PAGE 2) 12. TYPE OF BUSINESS (SEE DEFINITIONS ON PAGE 21

□ DISADVANTAGED □ WOMEN OWNED □ MANUFACTURER □ DISTRIBUTOR

BUSINESS BUSINESS

13. DUNS NO. !IF AVAILABLE) 1

14. DATE BUSINESS STARTED

15. FLOOR $PACE (SOU ARE FEETI A. MANUFACTURING 8. WAREHOUSE

1&. NET WORTH 

CERTIFICATION• I CERTIFY THAT IIFORMATIDN SUPPLIED HEREIN IINCLUOING All PAGES ATTACHED} IS CORRECT AND THAT NEITHER THE APPLICANT NOR ANY PERSOli (OR CONCERN} II ANY CONNECTION WITH THE APPLICANT 

AS A PRINCIPAL DR OFFICER, $0 FAR AS IS KNOWN, IS NOW DEBARRED OR OTHERWISE DECLARED IIEUGIBLE BY UY AGENCY OF THE FEDERAL GOVEll!IMENT FROM MAXING OFFERS FDR FURIISHIIG MATERIALS, SUPPLIES, DR 

SERVICES TD THE GOVERNMEIT OR ANY AGENCY THEREOF. IT IS UNDERSTOOD THAT ANY 01$CREPAIICIES OR OMISSIONS IN THIS APPLICATION WHEII COMPARED TO GOVERNMENT RECORDS MAY BE CAUSE FOR REJECTION OF 

MY APPLICATION. THE PENALTY FOR MAKING FALSE STATEMENTS IS PRESCRIBED IN 11. use. 1001. THE APPLICAH FURTHER AGREES, ONCE OUALIFICATION IS A TTAINEO. TO COUINUOUSLY MAINTAIN THEIR DUALITY SYSTEM 

IN COMPLIANCE WITH OSL CRITERIA. 

17 IIAME AND nm OF PERSOli AUTHDRIZ£0 TO SIGN (TYPE DR PRIil) 111. SIGIATUII£ 111. OAT£ SIGIEO

20. E-IIAILAODRESS: 121. PHONE NUMBER:

DSCP FORM 1696 E, 


REFERENCES 

To facllitate the Qualification Process, and eliminate unnecessary site-surveys, we reQuest that you prnvid-e the following information with regards to prior INDUSTRY 

surveys/audits conducted at your site within the last 18 months. Please also include data on association certifications, e.g. ISO 9002, NADCAP, etc. 

Ref Company Conducting I

Pofnt of contact at Conductlng Company Data & Purpose of mast Date !!1.11.iru!y Approved as a 

Survev/Audlt {lnctude telephone with Ar-ea Code) recent Survey I Aud It Supplier for that Company 

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DSCP FORM 5137, AUG 99