INTERNATIONAL VENDOR INFORMATION

Transcription

1 INTERNATIONAL VENDOR INFORMATION Please complete form and return all pages to issuing office. VENDOR ORGANIZATION Legal Name of Vendor: Website or Address: Registration #: TAX ID: Date of Registration/Date of Birth: Remit Payment To: Requests for Quotation(s) should be sent to: Point of Contact: Title: Payment Terms: Net TYPE OF ORGANIZATION (Check all that apply)_ Sole Proprietorship Manufacturer Partnership Distributor Corporate Entity (not tax-exempt) Wholesaler Corporate Entity (tax-exempt) Retailer Government Entity_ Contractor International Organization Consultant Foreign Government NGO Individual Other (Specify) BUSINESS SIZE & CLASSIFICATION (Check all that apply) Large Business Small Business Not-for-Profit (Specify Classification) Government Entity NGO By submitting this form you acknowledge HJF s Privacy Notice.

2 AFFILIATES 1 of VENDOR (if applicable identify below any and all AFFILIATES of VENDOR, attaching additional pages if necessary) 1 AFFILIATE means, with respect to any Person, any other Person that directly or indirectly through one or more intermediaries controls, is controlled by, or is under common control with such Person. For purposes of this definition, the term controls (including its correlative meanings controlled by and under common control with ) means the possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of a Person, whether through the ownership of voting securities, by contract, or otherwise. Person means any individual, corporation, limited liability company, general or limited partnership, joint venture, association, joint stock company, trust, unincorporated business or organization, government or agency or political subdivision thereof, or other entity, whether acting in an individual, fiduciary, or other capacity. 2

3 Does any owner, sales/service representative, or employee, have a personal or financial relationship with an employee of HJF or HJFMRI (include all site locations)? Yes No Is your firm or any of its Principals 2 presently debarred, proposed for debarment, suspended, or declared ineligible for the award of any contract by any U.S. Government agency? Yes No Within the last three-years has your firm, or any of its Principals, 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 U.S. Government contract or subcontract; violation of U.S. Government antitrust statues relating to the submission of offers; or embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property? Yes No Is your firm, or any of its Principals, presently indicted for, or otherwise criminally or civilly charged by any governmental entity with the commission of any of the offenses listed above? Yes No Has your firm, within the past three years, had one or more contracts terminated for default by any U.S. Government agency? Yes No Is your firm familiar with the Foreign Corrupt Practices Act of the United States of America (15 U.S.C. 78dd-l, et. seq.)? Yes No Is your firm willing to comply with the Foreign Corrupt Practices Act of the United States of America in its dealings on behalf of and in support of HJF and HJFMRI? Yes No Please have an authorized representative of your firm execute where indicated below. VENDOR NAME: SIGNATURE: PRINT NAME: TITLE: DATE: 2 Principals means officers: director, owner, partner, or other Person having primary management or supervisory responsibilities. 3

4 Wire Request Form (This request form must be submitted with each invoice for payment.) SECTION A: Beneficiary Account Name If account name is different from vendor name, please provide bank documentation verifying or evidencing account ownership, unless a formal invoice indicates business registration ID and doing business under such entity. Beneficiary Address: _ Beneficiary Bank: Bank Address: _ SWIFT Code: Bank Account Currency: Account Number/IBAN (required for some currencies): SECTION B: Intermediary/Correspondent Bank Name: (if applicable/receiving currency other than local currency): Intermediary SWIFT (if applicable): Please return all pages of completed form to issuing office. 4

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7 A Single Solution to Expand Your Research About HJF The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF) is a not-for-profit 501(c)(3) corporation dedicated to advancing military medicine. FH Non-Profit Authorized by Congress. Support USU Promote Military-Civilian Interchange Advance all DoD Medical Research Efforts Research Areas HJF leads research across many disciplines within military medicine. Cancer Chem Bio Rad Defense Clinical and Rehabilitative Combat Casualty Care Human Performance Infectious Disease Precision Medicine TBI/PTSD/Mental Health GLOBAL ORGANIZATION HJF offers military medical research and education services in nearly two dozen nations around the world. HJF understands the unique characteristics of working globally and has developed a wide variety of agreements and solutions to engage international research. HJFMRI HJF Medical Research International, Inc., is operated exclusively for charitable, educational and scientific purposes. The HJF subsidiary offers its international expertise to programs advancing medical research and providing care, treatment and education wherever their mission takes them. Our Expertise HJF answers the needs of the military medical community with a full range of expertise that allows researchers and clinicians to maintain their scientific focus and accomplish their research goals effectively and efficiently. Scientific Collaboration: Academia & Industry Global Research & Logistic Capabilities Funding Opportunity Searches & Alerts Technical Advising Proposal Development Tools & Specialists Program Management & Regulatory Support Clinical Trials Meeting & Conference Services Education & Training Support Graphics and Communications Support Conus & Oconus FUNDING INSTRUMENTS Navy Medicine Omnibus III Multiple Award ID/IQ Contract (W911QY-11-D-0053) Research and Development in the physical, engineering, and life sciences (except biotechnology) Army Contracting Command ACC - APG, Natick (W911QY-16-A-0013) Subcontractor on DTRA - Science and Technical Engagement Partnership Program (STEP)(HDTRA1-17-C-0019) Subcontractor on GSA One Acquisition Solution for Integrated Services (OASIS) Subcontractor on USAMRAA Research Activities Support Services (RASS) We take every reasonable measure to ensure that our business practices are ethically sound. We have developed a detailed Code of Ethics for our employees. The Code of Ethics is also available to our customers, suppliers, subcontractors and sponsors. HJF OFFICES Headquarters San Antonio,TX San Diego, CA Dayton, OH HJFMRI Regional Office 6720A Rockledge Drive, Suite 100 Bethesda, MD businessdevelopment@hjf.org 2787 Winfield Scott Road, Suite 220, JBSA Fort Sam Houston, TX Bob Wilson Dr. San Diego, CA hjf.org Wright-Patterson Air Force Base P.O Box Nairobi, Kenya bassefa@hjfmri.org