SRC Supplier Number: __________________
(to be completed by SRC DB Administrator)
DIRECT PROCUREMENT SUPPLIER PROFILE
For SRC
Please Fax Your Completed Form to the Appropriate Procurement Representative
It is imperative that you complete all applicable questions on this profile form; failure to do so will result in a rejection of your profile.
____________________________________________________________________________________________
Business Identification
1. Supplier Name: ________________________________________
Alternate Name: _____________________________________
Identification Numbers
Federal Taxpayer Identification Number: ______________________________________
Or Social Security Number of Holder: ______________________________________
and Name of Holder: __________________________________________________
Dun & Bradstreet Number _________________________________________________
If unknown, call (800) 333-0505 to obtain this number.
OR
Supplier profiles without a Dun & Bradstreet Number will require SRC Procurement Manager review and approval.
2. Your company is a (Check One):
OEM Manufacturer of ____________________
Contract Manager of ____________________
Distributor of ____________________
Subcontractor of ____________________
Tax Authority of ____________________
3. Type of Business Organization your Company operates as:
A U.S. corporation, incorporated under state laws in _____________________ .
U.S. Government Agency
U.S. Individual
U.S. Partnership
U.S. Non-Profit subject to OMB A-133
Foreign Corporation Foreign Individual
Foreign Government Agency Foreign Partnership
4. Export Compliance
SRC requires that its suppliers and subcontractors certify certain information necessary to ensure compliance with U.S. government export control laws and regulations. Adherence to this requirement is necessary before SRC will award, or continue to issue, any orders, participate in technical discussions or provide any items, data or assistance. This certification must be signed by duly authorized officer of your company.
Section 1: All SRC suppliers who are U.S. entities or persons must comply with the U.S. regulatory requirements contained in the U.S. International Traffic in Arms Regulations (ITAR); 22 CFR §122.1:
Any person who engages in the United States in the business of either manufacturing or exporting defense articles or furnishing defense services is required to register with the Directorate of Defense Trade. Manufacturers who do not engage in exporting must nevertheless register.
(a) Is your company registered with the Directorate of Defense Trade Controls, U.S. Department of State? Please check appropriate answer.
Yes _________ If yes, the registration expiration date is: ______________________________________
In process_________; date application submitted is: __________________________________________
No______________ Provide explanation below.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(b) Is your company foreign owned/controlled? Please check appropriate answer.
Yes __________ Provide explanation below.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
No __________
Section 2: Export Controlled Goods, Data, and Services: Supplier understands that certain goods, data, and/or services to be provided to SRC under a contract or purchase order may be subject to U.S. government export control laws and regulations including the International Traffic in Arms Regulations (ITAR) and the Export Administrations Regulations (EAR). Goods or data that are subject to export controls and provided by SRC will normally be clearly marked as such. Controlled services will also be clearly identified. The Supplier understands that they are obligated to contact SRC immediately to obtain an export control determination in cases where export control jurisdiction has not been clearly marked or otherwise identified by SRC. Supplier understands that providing access to U.S. export controlled goods, data, or services to non-U.S. persons either in the U.S. or abroad is prohibited without prior written authorization from the U.S. Government.
5. Company Identification
Company Name:_________________________________________________________
Main Phone Number:_________________________ Fax:_________________________
Address: _____________________________________________________________
City / State / Zip: _________________________________________________________
Company Contact:__________________________Phone:_______________________
Title: _______________________________ ______ Email:________________________
President/CEO: _______________________________________________________
Phone:_______________________ Email:_______________________________
Quality Manager:_________________________________________________________
Phone:_______________________ Email:_______________________________
6. Commercial and Government Entity Code (CAGE CODE): ___________________
CAGE codes are assigned by the Defense Logistics Agency: http://www.dlis.dla.mil/cage_welcome.asp
For more information, visit the System for Award Management at: https://www.sam.gov/portal/public/SAM/
Questions may be directed to the Federal Service Desk at: 866-606-8220
7. Has your company had a name change in the last three years? Yes No
If Yes, Identify previous name and address of company:
Company Name:__________________________________________________
Address: ________________________________________________________
City / State / Zip: __________________________________________________
8. Your company’s primary 6 digit North American Industry Classification System (NAICS) CODE:__________________________ To obtain NAICS information go to http://www.census.gov
9. A. Is your company presently debarred, suspended, proposed for debarment, or declared ineligible for award of contracts by any Federal Agency? Yes No
B. Has your company, 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 Federal, state or local government contract or subcontract; violation of Federal or state antitrust statute relation to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property? Yes No
C. Is your company presently indicted for, otherwise criminally or civilly charged by a Government entity with, commission of any of these offenses? Yes No
D. Your company certifies that they are compliant to FAR 52.209-5 Certification regarding debarment, suspension, proposed debarment, and other responsibility matters, FAR 52.222-22 Previous contracts and compliance records, FAR 52.222-25 Affirmative action compliance, FAR 52.203-11 Certification and disclosure regarding payment to influence certain federal transactions and FAR 52.223-13 Certification of toxic chemical release reporting. Yes No
10. Business Size Classifications (Indicate your company size according to FAR Part 19) See page 10 for definitions.
This question is not applicable to foreign business organizations.
Is your company a Large business? Yes No If Yes, Skip to Insurance Certification.
Is your company a Small Business? Yes No
Is your company a Woman-Owned Small Business? Yes No
Is your company a Veteran-Owned Small Business? Yes No
Is your company a Service-Disabled Veteran-Owned Company? Yes No
Is your company a Certified Small Disadvantaged Business (includes Minority-Owned) by the Small Business Administration? Yes No
Is your company a Certified HUBZone Small Business by the Small Business Administration?
Yes No
Are you a Historically Black College or University (HBCU), Minority Institution (MI), or Tribal College or University (TCU)? Yes No
If Yes, please identify the applicable classification: HBCU MI TCU
_____________________________________________________________________________________________________
Insurance Certification
PLEASE NOTE: SRC’s levels of insurance are identified below. You must submit your Certificate of Insurance naming SRC, Inc as additional insured.
If the company is an LLC, with employees, please submit workers compensation coverage to be included on the Certificate of Insurance as well.
A. Workers’ Compensation
Required for All Risk Levels:
Companies Workers’ Compensation – Statutory
Employers’ Liability- $1,000,000
Sole Proprietors may waive coverage depending on state domicile
B. Auto Liability
Required for All Risk Levels for vehicles used in the performance of the contracted work:
Company Vehicles Private Passenger Vehicles - $1,000,000 per accident covering all owned, nonowned
and hired vehicles.
Commercial Vehicles - $1,000,000 per accident covering all owned, non-owned
and hired vehicles.
Sole Proprietors without a commercial auto policy $500,000 per accident (personal lines policy)
C. General Liability
Low Risk $1,000,000 per occurrence, $2,000,000 aggregate
Examples of Low Risk Activities: Professional Services/Consultants, Training Activities (Classroom), Software Programmers, Couriers & Messengers, Audio & Video Equipment Suppliers/Installers, Office Machine Maintenance, Delivery Services, Fitness Training, Vendors coming on site:
· Product Displays on SRC Premises
· Suppliers sorting product
· Reworking previously purchased material (board assemblies)
· Testing high-end components, assemblies, etc…
Medium Risk $1,000,000 per occurrence, $2,000,000 aggregate plus $2,000,000 Umbrella
Examples of Medium Risk Activities: Painting/ Wall Paper Contractors, Plumbers, Furniture Movers,
Cafeteria/Food Service Providers, Landscapers (excluding tree cutting), Janitorial Services. Shredding and Document Destruction Services, Snowplowing
High Risk $1,000,000 per occurrence, $2,000,000 aggregate plus $4,000,000 Umbrella
Examples of High Risk Activities: Construction, HVAC contractors, Electrician, Industrial
Machinery Repair, Scaffolding/Lifts, Cranes, Welders/Soldering, Paving/Road Construction, Building Maintenance, Metal Working, Material Handling, Hazardous Materials, Remediation & Waste Management. Note, SRC reserves the right to require $9,000,000 Umbrella for certain projects that require higher limits based on exposure (ie, General Contracting-New Construction or Remodeling)
_____________________________________________________________________________________________________
Accounts Payable Information
W-9 Form Request
PLEASE NOTE: SRC requires that a completed W-9 form be attached with this Direct Material Supplier Profile form. Your company cannot be setup for payment until a completed W-9 form is received.
To obtain a copy of this form, go to http://www.forms.gov/ Search for “W-9”, and click GO.
Click on Request for Taxpayer Identification Number and Certificate.
If the company is an LLC (Limited Liability Company), please see the instructions below for completing the W-9:
If you are a single-member LLC (including a foreign LLC with a domestic owner) that is regarded as an entity separate from its owner under treasury regulations section 301.7701-3, enter the owner’s name on the “Name” line. Enter the LLC’s name on the “Business name” line.
Check the appropriate box for your filing status (sole proprietor, corporation, etc.), then check the box for “Other” and enter “LLC” in the space provided.
FOR CHECK PAYMENTS:
List REMIT TO address, if different from the Company Identification information noted in question #5.
Remit to Company Name_____________________________________________
Address: _________________________________________________________
City / State / Zip: ___________________________________________________
Contact Name:_____________________ Title: __________________________
Phone: _____-_____-_______ Fax: _____-_____-_______
Email:_______________________________________________________________
____________________________________________________________________________________________
Quality Questionnaire
Please check the characteristics that apply to your company.
11. Supplier Quality Profile and Self-Audit
Does your company’s quality system fully comply with:
ISO-9001 – 2008
AS9100 C
CMMI – Maturity Level III or greater
DO178B
DO254
Other(s) ____________________ ________________________
If your company’s Quality system is certified by a recognized, certifying organizations,
provide a current copy of the certification and proceed to question 26.
If your company’s Quality system is not certified to any of the above standards by an outside organization, please complete the following questions:
12. Supplier Responsibilities
Does your company…
have a documented quality system? (manual)
perform incoming inspections on procured materials?
have documented procedures/instructions?
make continuous improvement efforts?
13. Documentation and Records
Does your company have…
a system for identification, collection, filing, storage and retrieval of quality documentation and records?
14. Drawing and Specification Control
Does your company have…
a documented system for control of all drawings, revisions, specifications, and instructions used for fabrication, inspection and testing?
a system to ensure only the latest drawings and specifications are used?
a system to control customer deviations/waivers?
15. Measuring and Test Equipment
Does your company have….
a calibration system that includes all inspection, measuring & test equipment, and devices that effect product quality?
a system to readily distinguish calibration status?
suitable storage and handling of inspection equipment?
a documented calibration system?
Is your calibration system compliant to a recognized standard? If yes, list: _________________
16. Purchased Material Control
Does your company have a system…
that ensures purchased materials meet physical, chemical, visual, functional and dimensional requirements?
in which sub-contractor documentation records are maintained? (receiving)
that maintains records of statistical data, lot size, lot number and non-conformances with corrective action taken?
What sampling plan does your Receiving Inspection utilize? ____________________________
17. Process Control
Does your company have written procedures or quality plans for production of product including:
part number
part name
lot/order number
engineering/design revision level
control characteristics
sample size
frequency of checks
statistical data when necessary
gauging/measurement equipment
18. Final Inspection and Test
Does your company have…
a documented quality plan or written procedure for final inspection?
evidence that final inspections are being made and comply to purchase order requirements?
19. Material Identification and Control
Does your company have…
traceability of individual product or batches?
a system for segregation of non-conforming or scrap product from the normal production flow?
traceability integrated with your suppliers?
20. Non-Conforming Material Control
Does your company have…
established procedures to ensure that non-conforming product is prevented from inadvertent use?
a procedure for physical identification of the non-conforming product?
an area for isolating non-conforming product?
a procedure for disposition of non-conforming product? (rework, scrap, …)
a procedure to control the repair of product only with customer written concurrence?
21. Corrective Action
Does your company have a procedure for…
investigating cause of non-conformance and action to prevent recurrence?
analyzing processes, operations, quality records and customer complaints to detect and eliminate potential causes of non-conformance?
applying controls to assure corrective actions are effective?
implementing and recording changes in procedures resulting from corrective actions?
22. Internal Quality Audits
Does your company have.
a system to verify whether quality procedures and practices comply with the activities outlined in the quality manual?
23. Statistical Process Control
Does your company…
utilize statistical methods for never ending improvement in quality and productivity?
use statistical process control on control characteristics?
designate SPC to significant characteristics identified by the customer through knowledge of the production process or end use of the product?
24. Packaging and Shipping Requirements
Does your company have.
a documented system of procedures for handling, storage, packaging and delivery of product?
25. Advanced Quality Planning
Does your company utilize any quality planning techniques such as:
team approaches
FMEA
design of experiments
flow charts
SPC
establishing key characteristics
development of control plans
process potential studies
26. Indicate the number of employees your company has for each category:
A. Total Employees -
B. Design Engineer -
C. Manufacturing Engineer -
D. Quality Engineer -
E. Test Engineer -
27. Average Annual Gross Revenues
$1 million or less
$1,000,001-$2 million
$2,000,001-$3.5 million
$3,500,001-$5 million
$5,000,001-$10 million
$10,000,001-$17 million
Over $17 million
28. Indicate the number of shifts that your company runs:
29. Indicate the percent capacity your company is currently running at:
30. What type of manufacturing equipment is available?
31. What type of test equipment is available?
32. What processes does your company currently outsource (painting, plating, testing, calibration, etc.)
________________________________________________________________________________________
33. Purchase Order Text
I have reviewed the Internet site http://www.srcinc.com/suppliers.aspx for standard PO flowdown provisions and applicable terms and conditions.
____________________________________________________________________________________________
34. Certification
We certify all the foregoing representations and certifications are correct. We agree to notify SRC of any changes and updates on the information provided within this profile.
______________________________________ ____________________________
Authorized Signature Date Title
______________________________________ ____________________________
Printed Name Phone
__________________________________________________________
FOR SRC INTERNAL USE ONLY