ANNUAL SUPPLIER REPRESENTATIONS and CERTIFICATIONS

Transcription

1 ANNUAL SUPPLIER REPRESENTATIONS and CERTIFICATIONS Nammo Talley, Inc. must obtain certain certifications of compliance from companies who provide material, services and supplies for U.S. Government contracts. These certifications and representations are required prior to award of a subcontract and must be updated annually. Note: Some of the certifications are representations herein are similar to those solicited via the US Government Online Representations and Certifications Application (ORCA), however ORCA may not be used in lieu of this form. Complete all Sections as applicable. DO NOT LEAVE ANY SECTIONS BLANK. Offerors or Suppliers are not eligible for contract awards until annual certifications are on file. I. COMPANY INFORMATION Offeror / Supplier Name: DBA (if applicable) Business Mailing Address: City: County: State: Zip Code + 4 : Congressional District: Country: Phone Number: Address: DUNS Number: Fax Number: CAGE Code: Number of Employees last 12 months: Primary NAICS Codes: Offeror is or is not registered with the U.S. Government s Central Contractor Registration II. TYPE OF BUSINESS ORGANIZATION a. Offeror hereby certifies, that it is a U.S. Person as defined by the IRS which includes: o o o o an individual who is a US citizen or US resident alien; a partnership, corporation, company or association created or organized in the U.S. or under the laws of the U.S. an estate (other than a foreign estate) a domestic trust b. Federal Tax Identification Number (TIN); Employer Identification Number or SSN: c. Offeror, by checking the applicable box, represents that it operates as: a corporation incorporated under the laws of the State of a sole proprietorship a partnership TDS-2562 (NOV 2012) Page 1 of 9

2 a joint venture between an individual a Government Entity (Federal, State or local) a foreign entity, registered for business in (insert Country) an International organization per 26 CFR d. Offeror is owned or controlled by a common parent. Parent Company Name: Parent Company TIN: e. Offeror is a nonresident alien, foreign corporation that does not have income effectively connected with the conduct of trade or business in the U.S. and does not have an office or place of business in the U.S. Offeror is an agency or instrumentality of a foreign government A. SMALL BUSINESS PROGRAM FAR (Apr 2012 and Oct 2008), the OFFEROR represents that it is a: Small Business Large Business Foreign-Owned Business Historically Black College University or Minority Institution If a Small Business Concern, the Supplier represents that it is a: Small Disadvantaged Business concern as defined in 13 CFR (includes 8(a) certified businesses) Woman-Owned Small Business concern as defined in FAR (c) Veteran-Owned Small Business concern as defined in FAR (c) Service-Disabled Veteran-Owned Small Business concern as defined in FAR (c) HUBZone Small Business concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration (SBA), and no material change in ownership and control, principal office, or HUBZone employee percentage has occurred since it was certified by the SBA in accordance with 13 CFR Part 126 Alaska Native Corporations (ANCs) and Indian Tribes that have not been certified by the Small Business Administration as Small Disadvantaged Businesses Alaska Native Corporations (ANCs) and Indian Tribes that are not Small Businesses Small Business, but none of the above This representation must be in compliance with Federal definitions contained in the Code of Federal Regulations/Federal Acquisition Regulations (CFR/FAR). These definitions are available at Per 15 U.S.C. 637 (d), any person who misrepresents a firm s status as one of the above in order to obtain a subcontract shall: (i) be punished by imposition of fine, imprisonment, or both; (ii) be subject to administrative remedies, includes suspension and debarment and (iii) be ineligible for the participation in programs. B. CERTIFICATE REGARDING RESPONSIBILITY MATTERS FAR (Apr 2010) 1. a. The Offeror certifies, to the best of its knowledge and belief, that: TDS-2562 (NOV 2012) Page 2 of 9

3 i. The Offeror and/or any of its Principals: ARE ARE NOT presently debarred, suspended, proposed for debarments, or declared ineligible for the award of contracts by any Federal agency; HAVE HAVE NOT, within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract, violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property; ARE ARE NOT presently indicted for, or otherwise criminally or civilly charged by a Government entity with commission of any of the offenses enumerated above; HAVE HAVE NOT, within a three-year period preceding this offer, been notified of any delinquent Federal taxes (as defined in clause ) in an amount that exceeds $3,000 for which the liability remains unsatisfied. ii. The Offeror HAS HAS NOT, within a three year period preceding this offer, had one or more contracts terminated by default by any Federal Agency. b. Principals, for the purposes of this certification, means officers; directors, owners; partners; and, persons having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions). This Certification Concerns a Matter Within the Jurisdiction of an Agency of the United States and the Making of a False, Fictitious, or Fraudulent Certification May Render the Maker Subject to Prosecution Under Section 1001, Title 18, United States Code. 2. The Offeror shall provide immediate written notice to Nammo Talley, Inc. if, at any time prior to contract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Offeror s responsibility. Failure of the Offeror to furnish a certification or provide such additional information as requested by Nammo Talley, Inc. may render the Offeror nonresponsible. 4. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 5. The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Offeror knowingly rendered an erroneous certification, in addition to other remedies available to Nammo Talley, Inc., the Buyer may terminate the contract resulting from this solicitation for default. C. REPORTING EXECUTIVE COMPENSATION AND FIRST TIER SUBCONTRACT AWARDS (FAR ) (July 2010) The following questions (1-3) apply to sub-award recipients: 1. In the previous tax years, was your company s gross income from all sources under $300,000? Yes No 2. In your preceding completed fiscal year, did you receive: 1) 80% or more of annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements; and 2) $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements? Yes No (If your response to item 2 is No, please skip item 3 below and go to Section D) TDS-2562 (NOV 2012) Page 3 of 9

4 3 Does the public have access to information about the compensation of the senior executives through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d) or section 6104 of the Internal Revenue Code of 1986? Yes No Yes (if your response to item 3 is Yes, go to Section D No (if your response to item 3 is No, please be prepared, at a future date, to provide compensation information communicated below for your 5 most highly compensated executives.) Names: Positions: Salaries: (US dollar) D. BIOBASED PRODUCT CERTIFICATION (FAR ) (DEC 2007) As required by the Farm Security and Rural Investment Act of 2002 and the Energy Policy Act of 2005 (7 U.S.C. 8102(c) (3)), the Offeror certififies, by signing this offer, that biobased products (within categories of products listed by the United States Department of Agriculture in 7 CFR part 2902, subpart B) to be used or delivered in the performance of the contract, other than biobased products that are not purchased by the Offeror as a direct result of this contract, will comply with the applicable specifications or other contractual requirements. E. CERTIFICATION REGARDING KNOWLEDGE OF CHILD LABOR FOR LISTED END PRODUCTS (FAR )(FEB 2001) - $3,000 An award will not be made to an OFFEROR unless the Offeror, by checking the appropriate block, certifies to either paragraph A or B of this provision. A. OFFEROR will not supply any end product listed in paragraph C that was mined, produced, or manufactured in a corresponding country as listed for that end product. B. OFFEROR may supply an end product listed in paragraph C that was mined, produced, or manufactured in the corresponding country as listed for that product. The Offeror certifies that it has made a good faith effort to determine whether forced or indentured child labor was used to mine, produce, or manufacture such end product. On the basis of those efforts, the Offeror certifies that it is not aware of any such use of child labor. C. Listed End Product Listed Countries of Origin F. DISCLOSURE OF OWNERSHIP OR CONTROL BY THE GOVERNMENT OF A TERRORIST COUNTRY DFARS (JAN 2009) Offeror hereby certifies that it has compiled with this provision, as stated below, and provided all required disclosures, if any. 1. Definitions: a. Government of a terrorist country includes the state and the government of a terrorist country, as well as any political subdivision, agency, or instrumentality thereof. b. Terrorist country means a country determined by the Secretary of State, under section 6(j)(1)(A) of the Export Administration Act of 1979 (50 U.SC. App. 2405(j)(i)(A)), to be a country the government of which has repeatedly provided support for acts of international terrorism. As of the date of this provision, terrorist countries subject to this provision include: Cuba, Iran, Sudan, and Syria. c. Significant interest means i. Ownership of or beneficial interest in 5 percent or more of the firm s or subsidiary s securities. Beneficial interest includes holding 5 percent or more of any class of the firm s securities in nominee shares, street names, or some other method of hold securities that does not disclose the beneficial owner; ii. Holding a management position in the firm, such as a director or officer; iii. Ability to control or influence the election, appointment, or tenure of directors or officers in iv. the firm; Ownership of 10 percent or more of the assets of a firm such as equipment, buildings, real estate, or other tangible assets of the firm; or v. Holding 50 percent or more of the indebtedness of a firm. 2. Prohibition on award. In accordance with 10 U.S.C. 2327, no contract may be awarded to a firm or a subsidiary of a firm if the government of a terrorist country has a significant interest in the firm or subsidiary or, in the case of a subsidiary, the firm that owns the subsidiary, unless a waiver is granted by the Secretary of Defense. 3. Disclosure. If the government of a terrorist country has a significant interest in Offeror or a subsidiary of Offeror, Offeror shall disclose such interest in an attachment to its offer. If Offeror is a subsidiary, it shall also disclose any significant interest the government of a terrorist country has in any firm that owns or controls the subsidiary. The disclosure shall includea. Identification of each government holding a significant interest; and TDS-2562 (NOV 2012) Page 4 of 9

5 b. A description of the significant interest held by each government. G. DISCLOSURE OF OWNERSHIP OR CONTROL BY A FOREIGN GOVERNMENT DFARS (JUN 2010) (a) Offer hereby certifies that it has complied with this provision, as stated below, and provided all required disclosures, if any. Name of Foreign Government Entity: Identification of Foreign Government: Address of Entity Controlled by a Foreign Government: Description of Interest Ownership Percentage: (b) (c) (d) Definitions: (1) effectively owned or controlled: means that a foreign government or any entity controlled by a foreign government has the power, either directly or indirectly, whether exercises or exercisable, to control the election, appointment, or tenure of Offeror s officers or a majority of Offeror s board of directors by any means, e.g., ownership, contract, or operation of law (or equivalent power for unincorporated organizations). Prohibition on Award. In accordance with DFARS , no contract under a national security program may be awarded to an entity controlled by a foreign government as defined in (b) (3) of this provision if that entity requires access to proscribed information to perform the contract, unless the Secretary of Defense or a designee has waived application of 10 U.S.C (a). Disclosure: Offeror shall disclose any interest a foreign government has in Offeror when that interest constitutes control by a foreign government has in any entity that owns or controls the subsidiary, including reportable interest concerning Offeror s immediate parent, intermediate parents and the ultimate parent. Offeror shall provide the information required to be disclosed in the format as set out in Section G (a) above. (2) Entity controlled by a foreign government (i) Means (A) (B) Any domestic or foreign organization or corporation that is effectively owned or controlled by a foreign government; OR Any individual acting on behalf of a foreign government. (ii) Does not include an organization or corporation that is owned, but is not controlled, either directly or indirectly, by a foreign government if the ownership of that organization or corporation by that foreign government was effective before October 23, (3) Foreign government includes the state and the government of any country (other than the United States and its outlying areas) as well as any political subdivision, agency, or instrumentality thereof. (4) Proscribed information means (i) (ii) (iii) (iv) (v) Top Secret information; Communications security (COMSEC) material, excluding controlled cryptographic items when unkeyed or utilized with unclassified keys; Restricted Data as defined in the U.S. Atomic Energy Act of 1954, as amended: Special Access Program (SAP) information; OR Sensitive Compartmented Information (SCI). H. CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS FAR (Sep 2007) 1. The definitions and prohibitions contained in the clause at FAR , Limitation on Payments to Influence Certain Federal Transactions are hereby incorporated by reference into this Certification. 2. Certification: The Offeror, signing its offer, hereby certified to the best of its knowledge and belief that no Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on its behalf in connection with the awarding of this contract. TDS-2562 (NOV 2012) Page 5 of 9

6 3. Disclosure: If any registrants under the Lobbying Disclosure Act of 1995 have made a lobbying contact on behalf of the Offeror with respect to this contract, the Offeror shall complete and submit, with its offer, OMB Standard Form LLL, Disclosure of Lobbying Activities, to provide the name of the registrants. The Offeror need not report regularly employed officers or employees of the Offeror to whom payments of reasonable compensation were made. 4. Penalty: Submission of this certification and disclosure is a prerequisite for making or entering into a contract imposed by Section 31 U.S.C Any person who makes an expenditure prohibited under this provision or who fails to file or amend the disclosure form to be filed or amended by this provision, shall be subject to a civil penalty of not less than $10,000, and not more than $100,000, for each such failure. PROVISIONS I THROUGH K OF THESE REPRESENTATIONS AND CERTIFICATIONS ARE NOT APPLICABLE WITH RESPECT TO WORK PERFORMED OUTSIDE OF THE UNITED STATES BY EMPLOYEES WHO WERE NOT RECRUITED WITHIN THE UNITED STATES. I. NONSEGREGATED FACILITIES REQUIREMENTS (Modified FAR ) (applicable only if the US Government's solicitation sent to the Buyer includes FAR (APR 1984). Applies when contract is contemplated to include the clause Equal Opportunity. 1. CERTIFICATION OF NONSEGREGATED FACILITIES (Modified FAR ) (April 1984) a. Segregated facilities, as used in this provision, means any waiting rooms, work areas, rest rooms and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees, that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin because of habit, local custom, or otherwise. b. By the submission of this offer, the Offeror certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform their services at any location under its control where segregated facilities are maintained. The Offeror agrees that a breach of this certification is a violation of the Equal Opportunity clause in the contract. c. The Offeror further agrees that (except where it has obtained identical certifications from proposed subcontractors for specific time periods) it will i. Obtain identical certifications from proposed subcontractors before the award of subcontracts under which the subcontractor will be subject to the Equal Opportunity clause; ii. Retain the certifications in the files; and 2. NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR CERTIFICATION OF NONSEGREGATED FACILITIES A Certification of Nonsegregated Facilities must be submitted before the award of a subcontract under which the subcontractor will be subject to the Equal Opportunity clause. The certification may be submitted either for each subcontract or for all subcontracts during a period (i.e., quarterly, semiannually, or annually). J. PREVIOUS CONTRACTS AND COMPLIANCE REPORTS (Modified FAR (April 1984//February 1999). The Offeror represents that it 1. has participated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation, the clause originally contained in Section 310 of Executive Order or the clause contained in Section 201 of Executive Order and has filed all required compliance reports; or 2. has participated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation, the clause originally contained in Section 310 of Executive Order or the clause contained in Section 201 of Executive Order but has not filed all required compliance reports; or 3. has not participated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation, the clause originally contained in Section 310 of Executive order or the clause contained in Section 201 of Executive Order and therefore no compliance reports have been required K. AFFIRMATIVE ACTION COMPLIANCE (Modified FAR ) (Applies when the Offeror has 50 or more employees, or if the Offeror has employees that perform work at a construction site.) The Offeror represents that it: TDS-2562 (NOV 2012) Page 6 of 9

7 1. a. has developed, will maintain and has on file, or b. has not developed and does not have on file, at each establishment, a written affirmative action program required by the rules and regulations of the Secretary of Labor (41 CFR 60-1, 60-2 or 60-4) c. has not previously had contracts subject to the written affirmative action program requirement of the rules and regulations of the Secretary of Labor. 2. If 1.b is marked, then the Offeror represents that it will develop, maintain, update annually and have on file, at each establishment, a written affirmative action compliance program within 120 days from the commencement of any contract in excess of $50,000 it receives from the Buyer. PROVISION L OF THESE REPRESENTATIONS AND CERTIFICATIONS IS NOT APPLICABLE WITH RESPECT TO WORK PERFORMED OUTSIDE OF THE UNITED STATES AND ITS OUTLYING AREAS. L. CERTIFICATION OF TOXIC CHEMICAL RELEASE REPORTING (Modified August 2003/October 1995) (Applicable only if FAR is to be included in the resulting subcontract. Not applicable to solicitations for commercial items or for solicitations that are expected not to exceed $100,000.) The Offeror certifies that a. As the owner or operator of facilities that will be used in the performance of this contract that are subject to the filing and reporting requirements described in section 313 of the Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA) (42 U.S.C.11023) and 6607 of the Pollution Prevention Act of 1990 (PPA) (42 U.S.C ), the Offeror will file and continue to file for such facilities for the life of the contract the Toxic Chemical Release Inventory Form (Form R) as described in sections 313(a) and (g) of EPCRA and section 6607 of PPA; or b. None of its owned or operated facilities to be used in the performance of this contract is subject to the Form R filing and reporting requirements because each such facility is exempt for at least one of the following reasons: (check each block that is applicable) i. The facility does not manufacture, process or otherwise use any toxic chemicals listed in 40 CFR ; ii. iii. iv. The facility does not have ten (10) or more full-time employees as specified in section 313(b)(1)(A) of EPCRA, 42 U.S.C (b)(1)(A); The facility does not meet the reporting thresholds of toxic chemicals established under section 313(f) of EPCRA, 42 U.S.C (f) (including the alternate thresholds at 40 CFR , provided an appropriate certification form has been filed with EPA); The facility does not fall within the following Standard Industrial Classification (SIC) ([see or their corresponding North American Industry Classification System (NAICS) sectors [see (A) Major group 10 (except 1011, 1081, and 1094). (B) Major group 12 (except 1241). (C) Major group codes 20 through 39. (D) (E) Industry code 4911, 4931, 4939 (limited to facilities that combust coal and/or oil for the purpose of generating power for distribution in commerce). Industry code 4953 (limited to facilities regulated under the Resource Conservation and Recovery Act, Subtitle C (42 U.S.C. 6921, et seq.)), or 5169, 5171, 7389 (limited to facilities primarily engaged in solvent recovery services on a contract or for fee basis); or v. The facility is not located within any state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the United States Virgin Islands, the Northern Mariana Islands, or any other territory or possession over which the United States has jurisdiction. M. BUY AMERICAN ACT CERTIFICATE (FEB/2009) (For all solicitations where is in contract) TDS-2562 (NOV 2012) Page 7 of 9

8 1. The Offeror certifies that each end product, except those listed in paragraph (b) of this provision, is a domestic end product and that for other than COTS items, the Offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The Offeror shall list as foreign end products those end products manufactured in the United States that do not qualify as domestic end products, i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) of the definition of domestic end product. The terms commercially available off-the-shelf (COTS) item, component, domestic end product, end product, foreign end product, and United States are defined in the clause of this solicitation entitled Buy American Act - Supplies. 2. Foreign End Products: Line Item No.: Country of Origin: (List as necessary) 3. Nammo Talley, Inc. will evaluate offers in accordance with the policies and procedures of Part 25 of the Federal Acquisition Regulation. N. EXPORT CONTROL AND DEPARTMENT OF DEFENSE TRADE CONTROLS (DDTC) REGISTRATION CERTIFICATION Export Control Be advised that nearly all Nammo Talley products are categorized as defense articles under the United States Munitions List, 22 C.F.R., Part 121. I understand that Nammo Talley, Inc. may provide our company with technical data, hardware, or other tooling (e.g., documentation, software, drawings, and specifications) as defined and regulated by the U.S. International Traffic in Arms Regulations (ITAR) in 22 CFR Parts and the U.S. Export Administration Regulations (EAR) 15 CFR Parts and are subject to export control laws of the U.S. Government. I understand that employees, agents, or representatives of our company may not transfer such technical data, hardware, or other tooling by any means to a foreign person, whether in the United States or another country, without prior written approval from Nammo Talley, Inc. and the U.S. Government. Additionally, employees of our company that are a foreign person will not have access to any technical data, hardware, or other tooling supplied to us by Nammo Talley, Inc. Written permission from Nammo Talley, Inc. must be obtained prior to transferring the technical data, hardware, or other tooling to any other company or non-u.s. person in the United States or any other country. Our company has effective measures in place to prevent the export of the technical data, hardware, or other tooling provided by Nammo Talley, Inc. to a foreign person in the United States or other country without the applicable prior written approval of the U.S. Government and Nammo Talley, Inc. In accordance with the Arms Export Control Act and pursuant to ITAR section 122.1, our company: (Select one) is registered with the DDTC, a copy of the registration is current and will be provided to Nammo Talley upon request. is not currently registered; however, is involved in the manufacturing of defenses articles and/or furnishing defense services requiring registration. Registration request will be submitted within 30 days and proof of registration will be provided upon request. is not required to be registered; we are not involved in the manufacturing of defense articles and/or furnishing of defense services. A copy of the letter from the Dept. of State indicating that registration is not required will be provided to Nammo Talley. NOTE: DDTC Registration Defense Articles and Defense Services: In accordance with the Arms Export Control Act and pursuant to ITAR section 122.1, if your business is involved in either the exporting or the manufacturing of defense articles, or furnishing of defense services as defined in the Arms Export Control Act you are required to register with the U.S. Department of State Directorate of Defense Trade Controls (DDTC) and have an effective program in place to insure compliance to these regulations. For registration details see Please ensure you have read the above ITAR citations and understand the definition of defense articles and defense services. TDS-2562 (NOV 2012) Page 8 of 9

9 O. ADDITIONAL CERTIFICATIONS Offerors are hereby advised the additional certifications may be required at the time of acquisition. These certifications are required at certain dollar thresholds if specific Public Laws are incorporated into the terms of the contract (at $700,000 and above unless the contract dictates a lower threshold). Specifically these include Subcontractor Cost or Pricing Data (FAR ) and Cost Accounting Standards (FAR ). In the event these clauses are required contractually, offerors shall submit the required information and associated certifications unless otherwise exempt as specified in the FAR clauses referenced. CERTIFICATION I hereby acknowledge an understanding of the United States Government contracting and subcontracting programs and confirm the accuracy of the statements made above. This certification shall apply to all solicitations, agreements, purchase orders or subcontracts received from Nammo Talley, Inc. and shall be valid for one year from date of execution. The Offeror verifies by submission of this document that the representations and certifications shown above are current, accurate, and complete as of the date executed. OFFEROR S EXECUTION Offeror s signature below applied to all provisions above. Company: Address: Name (Print or Type): Signature: Title: (Offeror s location where performance will occur) Date: Telephone No.: Fax No.: Address: TDS-2562 (NOV 2012) Page 9 of 9