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Supplier Registration Form

Company Name  
Contact Person  
Address  
E-Mail Address    
City  
State  
Zip  -   
Phone      
Fax  
Web Address
Dunn & Bradstreet No.
Please give a description of your Products, Supplies, Services etc.

Business Classification


1. Please identify the business classifications for which you qualify by marking the appropriate box(es) below. Refer to the definition of each classification as listed on the reverse side of this form.
Number of Employees   

**You must furnish a copy of your certification (local, regional or national) with these classifications

2. If your firm qualifies as a Small Disadvantaged, Minority or Woman-owned Business as defined by FAR 52.219, please designate your classification by marking the box for at least one of the categories shown below **


3. Company Classification:

Parent Company
Address
City/State/Zip

I hereby certify that the foregoing information regarding business size and business ownership is true and correct.

*Note: Completion and submission of the registration form does not guarantee your status as an approved/preferred Asurion Supplier. Your company will be entered into the Supplier Diversity Database for further consideration based on internal business needs.

Definitions - Business Classifications


SMALL BUSINESS: A small domestic concern must be independently owned and operated and not dominant in its field of endeavor. Generally speaking, a company employing fewer than 500 persons is considered small. Refer to 13 CFR (Code of Federal Regulations); 121 FAR (Federal Acquisition Regulations) 19-101, 10-102, or consult your regional Small Business Administration for specific definitions.

SMALL DISADVANTAGED BUSINESS: A socially economically disadvantaged small domestic concern at least 51% owned, and daily managed and controlled, by socially and economically disadvantaged individuals; or in the case of publicly owned business at least 51% of the stock is owned by socially economically disadvantaged individuals and one or more such individuals manage and control the daily operations of the business. Disadvantaged persons are individuals found to be disadvantaged by the Small Business Administration. Refer to PL 95-507, FAR 19-101, or 13 CFR Part 124 for further clarification.

WOMEN-OWNED: At least 51% of the concern is owned and day-to-day managed and controlled by women, or in the case of a publicity owned business, at least 51% of the stock is owned by women and one or more such individuals manage and control the daily operations of the business (FAR 52-219).

VETERAN or SERVICE-DISABLED VETERAN: Not less that 51% of which is owned by one or more veterans as defined at 38 U.S.C. 101(2) or service-disabled veterans as defined at 38 U.S.C. 101(16). The management and daily business operations of which are controlled by one or more veterans or in the case of a service-disabled veteran with permanent or severe disability, the spouse or permanent caregiver of such veteran.

HUBZone: A small business concern that appears on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration.

NON-PROFIT ORGANIZATION: Any organization not conducted or maintained for the purpose of making profit. Included in this category are: sheltered workshops, universities, colleges, and local state, and federal governments, etc.

NOTICE. Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a small business concern as defined in FAR paragraph (a) 52.219, Small Business Concern Representation, which defines that criteria needed in order to obtain a contract that is 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 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 Act.