State Zip Code. Does the vendor share office space, staff, equipment or expenses with any other entity?

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1 Page 1 of 2 VENDOR INFORMATION Please provide the following information: Vendor Name: Address City State Zip Code Address: Phone Number: EIN/TIN DBA DUNS Number Does the vendor share office space, staff, equipment or expenses with any other entity? No Yes Business Category Professional Services Commercial Services Construction Manufacturing Distribution Retail Human Services for-profit Date Formed State Formed

2 Page 2 of 2 Business Type (Corp., LLC, etc.) New York State Certifications held by Firm: NYS Minority Owned Business Enterprise NYS Women Owned Business Enterprise NYS Dual Minority and Women Owned Business Enterprise None of the Above Other NYC Certifications held by Firm: NYC Minority Owned Business Enterprise NYC Women Owned Business Enterprise NYC Dual Minority and Women Owned Business Enterprise NYC Locally Owned Business Enterprise None of the Above Other Does Vendor have any affiliates and/or entities that control or are controlled by the vendor: Yes No

3 Page 1 of 2 AFFILIATES AND/OR ENTITIES List with EIN any affiliates and/or entities that control or are controlled by the vendor: 1. Entitiy Name: 1. Address City State Zip Code 1. EIN# 1. Vendor's relationship to Entity: 2. Entitiy Name: 2. Address City State Zip Code 2. EIN# 2. Vendor's relationship to Entity: 3. Entitiy Name:

4 Page 2 of 2 3. Address City State Zip Code 3. EIN# 3. Vendor's relationship to Entity: 4. Entitiy Name: 4. Address City State Zip Code 4. EIN# 4. Vendor's relationship to Entity: Are there any additional Affiliates and/or Entities? Yes No

5 Page 1 of 3 PRINCIPAL INFORMATION (Include all principal owners and officers exercising the most control) PRINCIPAL INFORMATION 1. Name First Name Last Name 1. DOB 1. Position 1. % Ownership 1. Phone Number 1. Address 2. Name First Name Last Name 2. DOB 2. Position 2. % Ownership 2. Phone Number

6 Page 2 of Address 3. Name First Name Last Name 3. DOB 3. Position 3. % Ownership 3. Phone Number 4. Name First Name Last Name 4. DOB 4. Position 4. % Ownership 4. Phone Number Are there any Additional Principals? Yes No

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8 Page 1 of 1 PRINCIPAL OWNERSHIP IN OTHER ENTITIES For Each Principal, list all entities in which the principal owns 20% or more of such entity below. Do any principals have ownership in any other entities? Yes No

9 Page 1 of 1 CONTRACT INFORMATION PROJECT NAME: PROJECT NUMBER: Vendor's Relationship to this Contract: Prime Contractor Subcontractor to Prime Subcontractor to a Subcontractor Type of Work to be Preformed: Contract Amount ($): If you are a Subcontractor, please enter the name of the firm that holds your contract:

10 Page 1 of 2 GENERAL RESPONSIBILITY QUESTIONS At any time during the past five (5) years, has the vendor, any affiliate, or any other entity in which the principals/officers of the vendor are/were principals/officers, been subject to the following, whether pending or completed: Debarred from entering into any government contract? Found nonresponsible on any government contract? Declared in default and/or terminated for cause? Determined to be ineligible to bid or propose on any contract? Suspended from bidding or entering into any government contract? Received an overall unsatisfactory performance rating from any government agency on any contract? Are there or have there been any judgments, injunctions or liens, including but not limited to, judgments based on taxes owed, fines and penalties assessed by any government agency against the vendor, any affiliate or any other entity in which the principals/owners of the vendor are/were principals: At any time in the past five (5) years? That remain open, unsatisfied, or in effect today?

11 Page 2 of 2 Have any bankruptcy proceedings been initiated by or against the vendor or its affiliates within the past seven (7) years (whether or not closed) or is any bankruptcy proceeding pending against the vendor or its affiliates regardless of date? Is there any litigation pending or threatened, or other existing or pending condition, claim or event that may significantly affect the financial status of the vendor or any affiliate? In the past five (5) years, has the vendor, any of its principal owners or officers, or any affiliate: Had any permit, license, concession, franchise or lease terminated for cause or revoked? Been disqualified for cause as a bidder on any permit, license, concession, franchise or lease? Received any OSHA citation and Notification of Penalty containing a violation classified as serious or willful? Had a government entity find a willful prevailing wage or supplemental payment violation? Had a New York State Labor Law violation deemed willful?

12 Page 1 of 1 INVESTIGATIONS In the past five (5) years, has vendor or any affiliate or any individual currently or within that period serving as a principal owner, officer or managerial employee been investigated by any government agency, including any federal, state and local regulatory or law enforcement agencies? In the past five (5) years, has vendor or any affiliate or any individual currently or within that period serving as a principal owner, officer or managerial employee been subpoenaed before a grand jury, federal, state or city department, commission or agency to testify in an investigation or produce records (including voluntary participation) concerning any transaction or contract with a government entity? In the past five (5) years, has vendor or any affiliate or any individual currently or within that period serving as a principal owner, officer or managerial employee, during the course of, or in an action, a proceeding or investigation, been granted immunity from prosecution?

13 Page 1 of 1 CRIMINAL CHARGES/CONVICTIONS Has the vendor, any affiliate, or any of their current or former principal owners or officers or managerial employees: Been convicted of a misdemeanor and/or found in violation of any administrative, statutory, or regulatory provisions in the past five (5) years? Been convicted of a felony in the past ten (10) years? Have any felony, misdemeanor and/or administrative charges currently pending? For each question above with a "Yes" answer, attach any relevent documentation as a single PDF document here: Attach Documentation Browse... Attach Documentation Browse... Attach Documentation Browse... Should you require, you can save answers now by clicking below, and resume later to complete this form when you have compiled the required documents.

14 Page 1 of 1 CERTIFICATION A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS DISCLOSURE APPLICATION MAY RESULT IN RENDERING THE VENDOR NRESPONSIBLE WITH RESPECT TO THE DISCLOSURE APPLICATION SUBMISSION AND, IN ADDITION, MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRIMINAL CHARGES. THIS FORM IS INTENDED TO BE A WRITTEN INSTRUMENT UNDER ARTICLE 175 OF THE NEW YORK STATE PENAL LAW. I certify that the information set forth in or attached to this Vendor Disclosure Application is true and correct to the best of my knowledge, information and belief, and I understand that the making of any false statement in this form or any attachment is a class E felony. I further certify that no public, College, or CUNY employee, officer, or person whose salary is payable in whole or in part, directly or indirectly, from the City Treasury or State Treasury is directly or indirectly interested in the subject transaction or in the goods or services to which it relates or in any portion of the profits thereof. Name First Name Last Name I affirm and submit electronically. Subscribed to under penalty of perjury under the laws of the State of New York, this day of, 20 as the act and deed of said corporation, partnership, or individual.

15 Page 1 of 1 Confirmation Page Your Aplication has been completed Sucessfully. Thank you for your submission. Should you have any questions pertaining to this submission, please send an to vii.vdf@cuny.edu. Submit