Supplier Questionnaire
FIELDS MARKED WITH
*
ARE REQUIRED!
Contact Information
*
Company Name
*
Address
(Address 2)
*
City
*
State
-- Select One --
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NV
NM
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Non-US
Province
*
Country
*
Zip
*
EMAIL
*
Phone
-
-
Ext
*
Fax
-
-
Website Address
Business Specific Information
*
D & B Rating
YES
NO
*
(Enter D & B Rating)
*
DUNS Number
*
Registered in Central Contracting Registry (CCR)?
Yes
No
Type
>
-- Select One --
Manufacturer
Distributor
ServiceProvider
*
Owner
E-Verify?
YES
NO
*
3-yr Avg. Sales Rcpts.
*
NAICS Code(s)
(Space Separated)
*
Number of Employees
*
Number of Years in Business:
Product Information
*
Previous Year Sales
-- Select One --
< 1M
2-4M
> 5M
*
Primary Commodity/Service
Product Lines
Company Classification
-- Select One --
Division of
Affiliate of
Subsidiary of
*
Major Customers (e.g., gov, schools, etc.)
*
Business Qualifications (select at least one)
Small Business (SB)
Certified SDB
Certified 8(a)
Woman-owned SB
Qualified HUB Zone
Service Disabled Veteran-owned SB
Veteran-owned SB
HBCU/MI Black Colleges, University/Minority Institution
Large Business
*
Manufacturing Type (select at least one)
Manufacturing/Assembly
Raw Materials
Services
Distributor
Level 1 Supplier - (check if you are a qualified Level 1 supplier)
*
Quality System (select at least one)
None
MIL-Q-9858
MIL-I-45208
EB2678
NQA-1
ISO - Certification
ASME
Other
*
Price Verification (Yes or No on each)
Published Price List
YES
NO
GSA Schedule
YES
NO
Integrated Contractor Procurement Team (ICPT)
YES
NO
*
Safety Performance Standards (Yes or No on each)
Interstate Experience Modification Rate (EMR)
YES
NO
*
(Enter the EMR Rate)
3 Year Average Total Recordable Case Rate (TRC)
YES
NO
*
(Enter the TRC Rate)
Past Performance Documentation
Any other contracts/Subcontracts from past 2 years
YES
NO
References, point of contact information
*
*
Dollar value of contracts/Subcontracts from past 2 years
Construction subcontractors only
Bonding Capacity?
YES
NO
*
Bonding Company:
*
Contact Information:
*
Bonding Capacity:
*
Amount currently bonded:
Value Added Services
*
Electronic commerce (receive PO's and send invoices)
YES
NO
If YES, how? EDI, internet, both?
*
E-Business capabilities
YES
NO
*
Accept procurement cards
YES
NO
*
Brief Company Capability Statement
*
NOTICE: Under 15 USC 645 (d), any person who misrepresents a firm's status as a small, HUBZone small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to sections 8(a), 8(d), 9 or 15 of the Small Business Act or any other provision of Federal Law that specifically references section 8(d) for a definition of program eligibility, shall -- (1) Be punished by imposition of fine, imprisonment or both (2) Be subject to administrative remedies, including suspension and debarment; and (3) Be ineligible for participation in programs conducted under the authority of the act.
*
Certify Accuracy
Form Submittal
*
Submitted By
*
Title
Savannah River Nuclear Solutions, LLC / A Fluor Daniel Partnership