Vendor Profile and Setup Form

Vendor Certifies as follows (please check and fill in all information that is applicable)
*
*
Payment Terms:  

Vendor Information
Name of Company *
  		Telephone No *
 
Street Address *
  		Fax No.
 
Street Address
  		E-Mail Address *
 
City *
  		Doing Business As
 
State *
  		Web Address/URL
 
Zip *
  		Contracts Contact Name
 
Country
  		Parent Company/Subsidiaries
 
Name of Responsible Company Officer and Title
  		EIN/Social Security No./Tax ID No./VAT (No Hypens)*
 
No. Employees This Location
  		Total Number of Employees with Company
 
Remittance Address - Street Address *
  		Remittance Address - Line 2
 
Remittance Address - City *
  		Remittance Address - State *
 
Remittance Address - Zip Code *
  		Remittance Address - Country
 
Data Universal Number System (DUNS) *
  		Cage Code
 
UEID *
  		 

W9 Tax Information
Name(as shown on your income tax return)
   OR Business Name (as shown on your income tax return)
(Please enter either Name or Business Name, not both.)
Check the appropriate box for federal tax classification:*
Individual/Sole Proprietor/Single member LLC
C Corporation
S Corporation
Partnership
Trust/Estate
Limited Liability Company
(Enter the tax classification (C= C Corporation, S- S Corporation, P= Partnership)
Note: For a single –member LLC that is disregarded, do not check LLS; check the appropriate box in the lines above for the tax classification of the single-member owner.
Other

Exemptions (codes apply only to certain entities, not individuals; see IRS instructions by following http://www.irs.gov/pub/irs-pdf/fw9.pdf
Exemption from FATCA reporting code (if any)
 
1099 Address (if different from above)
Address (number, street, and apt. or suite no)
City, state, and ZIP code
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Name of Person Certifying *
  		Title *
 

Method of Payment*
Please enter your bank information below:
Bank Name:*
  		Amount or Percentage:
 
Account No.*
  		Routing No.*
 

North American Industry Codes (NAICS)
Primary NAICs *

 Secondary NAICs
Primary NAICs' Business Size:   Secondary NAICs' Business Size: 

Socio-Economic Status*
Small Business Large Business
Woman-Owned Business Non-Profit
Veteran-Owned Business Disadvantaged Business (Including Mintority Owned)
ANC Historically Black Colleges & University
HUBZone Service Disabled Veteran-Owned
Foreign-Owned
  Have you been certified of your Socio-economic status in either SAM or SBA Dynamic Small Business Data base System?
  Is your company a certified Service Disabled Veteran Owned small business concern?

Small Disadvantaged Business/Woman Owned Small Disadvantaged Business/Service Disabled Veteran or Woman Owned Small Business
  If you are a Small Disadvantaged Business or a Woman Owned Small Disadvantaged Business, have you been certified by the SBA?
  If you are a Small Disadvantaged Business or a Woman Owned Small Disadvantaged Business are you listed in the SBA’s Central Contractors Registry as being a certified SDB?
  If you are a Small Disadvantaged, Woman Owned Small Disadvantaged, Service Disabled Veteran or Woman Owned Small Business, are you also certified by the SBA as a HUBZone Small Business concern?
If you are a Small Disadvantaged Business or a Woman Owned Small Disadvantaged Business, please provide the primary NAICS Code for the products or services you provide to NTT DSFG
 

Certification Regarding Debarment, Suspension, etc.
The Vendor certifies, to the best of its knowledge and belief, that the Vendor and/or any of its principals:
* presently debarred, suspended, proposed for debarments, or declared ineligible for the award of contracts by any federal agency;

The Vendor and/or any of its principals *, within a 3-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, or receiving stolen property; and,

The Vendor and/or any of its principals * presently indicted for, or otherwise criminally or civilly charged by, a governmental entity with commission of any of the above offenses.
The Vendor *, within a 3-year period preceding this offer, had one or more federally-funded contracts/subcontracts terminated for default.
*  Has your company ever done business with NTT DATA, Inc. or any of its subsidiaries? If yes, please provide the names of each NTT DATA company:
 
*  Has your company or any of its subsidiaries ever been disqualified/disbarred by NTT DATA, Inc., any of its subsidiaries, or the federal government? If yes, please provide the details:
 
*  Has your company currently, or has it in the last 5 years, received a cure or termination notice? If yes, please provide the details:
 
*  Has your company currently, or in the past, filed for bankruptcy?
If yes, please provide the details:
 
*  Are there any court orders affecting your company or any liens or judgments filed against it? If yes, please provide the details:
 

General Questions
*  Do you display DoD hotline posters, Fraud, Waste, Abuse, Whistle Blower, DoD hotline or Human Trafficking posters?
*  Do you have an accounting system accepted by a DCAA?
      Approval Date
*  Do you have a billing (management) system formally approved by a DCAA?
      Approval Date
*  Do you have a DCAA approved estimating system?
      Approval Date
*  Is this proposal consistent with your established estimating and accounting practices?
If No, please explain:
*  Do you have a DCAA approved Purchasing System?
      Approval Date
*  Do you have a DCAA approved Property Control System?
      Approval Date
*  Has your company filed all required compliance Reports?
*Do you have systems and processes in place to submit your annual incurred cost proposal to the government?
If N/A please provide Explanation:  
*  Do you currently maintain a facility security clearance?
If Yes, what level:
Name of FSO
Expiration date of current facility clearance:  
* Do you currently have personnel that maintain a security clearance?
If Yes, what level:
Name of FSO
Expiration date of current applicable clearance:  
*  Are the products or services provided considered commercial in accordance with FAR 2.101?
*  Are your services/products TAA certified?

Relationships
*  Is anyone employed or contracted by your company related by blood or marriage to anyone who works with, or for, NTT DATA, Inc. or any of its subsidiaries? If yes, please provide the full name of the individual(s) and the name of the agency, organization, or company for which they work or are associated:

Capabilities
This is a free flowing block. Add your company’s capabilities. Not more than 10 areas. i.e., help desk, electronics, engineering, program management, etc.*
Name three agencies that you support using your main capabilities?
Agency:
Agency:
Agency:

NOTICE: In accordance with U.S.C. 645(d), any person who misrepresents a firm’s proper size classification shall: (1) be punishable 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 Small Business Act.

NTT DATA Procurement POC *
SCA/Buyer:

The above information is certified true and correct by
Vendor Name:*
Name:*
Title:*