Vendor/Contractor Requirements

Supplier Information

UR Medicine Home Care, as a contractor to the US Government, is required to collect and report supplier size information for certain subcontracting reports.

Required fields marked with asterisk (*)

Corporate Name or Parent Company and Corporate Address*:

DBA (Doing Business As) Name*:

NPI # (if applicable):

DBA Address*:

City*:

State*:

Zip Code*:

CEO*:

Primary NAICS Code*:

Estimated Annual Sales*:

VP of Sales/Marketing*:

Average Number of Employees*:

Supplier Size*:

Small Disadvantaged Business?*:

YesNo

Applicable SDB Classification*:

Hub Zone Small Business (SBA Certified)?*:

YesNo

Woman Owned Small Business?*:

YesNo

Veteran Owned Small Business?*:

YesNoService Disabled

Alaska Native Corporation?*:

YesNo

Indian Tribes?*:

YesNo

Second Tier Program?*:

YesNo

Certified? (Federal, State, Regional)*:

YesNo

Business Type*:

Company Category*:

Products or Services (1)*:

Products or Services (2):

Products or Services (3):

You may wish to review the definitions for the above categories in the Federal Acquisition Regulation 19.7 or 52.219-8 (https://www.acquisition.gov/?q=browsefar). If you have difficulty ascertaining your size status, please call 1-800-U-ASK-SBA or refer to SBA's website.

Contact Information

Contact Person*:

Email Address*:

Phone Number*:

( ) -

Fax Number*:

( ) -

Web Address:

DUN & Bradstreet:

UEI#:

Year Established (yyyy):

Principal Client/Customer References:

*Does any UR Medicine Home Care (URMHC) employee, or a close relative or member of his or her household, who has or will participate in the decision to acquire goods and/or services from your company (1) own 5% (or more) stock or other interest in your company (2) serve as an officer, director, employee, proprietor, partner, trustee, or consultant of your company; (3) stand to profit financially or personally in any way from the acquisition by the University of goods and/or services from your company; or (4) receives compensation in any form or in any amount from your company?

YesNo

*Any situation where a University of Rochester staff or its affiliates, faculty or student and/or his or her spouse or emancipated and /or minor children has a connection to the above referenced supplier.

If you answered yes, please complete the following section:

URMHC Employee Name:

Phone Number:

( ) -

Employee's Relationship or Position within the Company:

Under 15 U.S.C. 645(d), any person who misrepresents its size status shall (1) be punished by a fine, imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act.

Company Representative Information

Company representative submitting this information and validating that this information is correct:

Name*:

Title*:

Date*:

Phone Number*:

( ) -

Email Address:

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