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SUPPLIER CERTIFICATION FORM
Supplier Name:
Address:
City, State, Zip:
Telephone:
E-mail Address:
Tax Id. No.
Corporate Status:
Corporation
L.L.C.
Partnership
Limited Partnership
Individual
1. Our company is classified as indicated below (check all that apply). We agree to provide MPC written notice within thirty- (30) days in the event that any classification certified to below changes.
Large Business
Government or Education
Small Business

(if checked, complete information below)

Representations:
Woman-Owned Small Business
HUBZone Small Business         Applicable Zip Code for HUBZone
Veteran-owned Small Business
Service-Disabled Veteran-Owned Small Business
Certified Small Disadvantaged Business

(if checked, complete information below)

Representations:
(1) General. The contractor or supplier represents, as part of its offer, that it is a small business under the size standard applicable to this acquisition; and either--
(i) It has received certification by the Small Business Administration as a small disadvantaged business concern consistent with 13 CFR 124, Subpart B; and
(A) No material change in disadvantaged ownership and control has occurred since its certification;
(B) Where the concern is owned by one or more disadvantaged individuals, the net worth of each individual upon whom the certification is based does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2); and
(C) It is identified, on the date of its representation, as a certified small disadvantaged business concern in the database maintained by the Small Business Administration (PRO-Net); or
(ii) It has submitted a completed application to the Small Business Administration or a Private Certifier to be certified as a small disadvantaged business concern in accordance with 13 CFR 124, Subpart B, and a decision on that application is pending, and that no material change in disadvantaged ownership and control has occurred since its application was submitted.
2. We certify that, when applicable, we are in compliance with the requirements of the following FAR clauses:

FAR 52.219-8, "Utilization of Small Business Concerns";
FAR 52.219-9, "Small Business Subcontracting Plan";
FAR 52.222-26, "Equal Opportunity";
FAR 52.222-35, "Affirmative Action for Disabled Veterans and Veterans of the Vietnam Era";
FAR 52.222-36, "Affirmative Action for Workers with Disabilities"; and,
FAR 52. 52.222-41, Service Contract Act of 1965, As Amended (41 U.S.C. 351, et seq.).
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