Talk to Tech :: Talk to Customer Service :: Shopping Cart :: Login
	Search Catalog         |  Search Tips

Catalog   Services   Who We Serve   Closeouts   My Black Box   About Us   Contact Us   Tech Support   Customer Service   |   Home

Profile Order Status/History Quotes Status/History Warranty Information Shipping Address Request A Catalog Express Order Entry

Vendor Questionnaire Black Box  > Small Business Please complete the form below and submit for review by Black Box Small Business Subcontracting Program Administrator. Small Business Supplier Information   Supplier Company Name: * Control Number:   Your control number can be located in the upper right hand corner of the letter of instructions that you received. Address 1: * Address 2: City: * State: * Choose One... Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota N. Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming   Postal Code: *   Contact First Name: *   Contact Last Name: *   Contact Title: E-mail address: *   Telephone: *   Ext :    Fax:   Ext :          Commodity or Service Provided: Commodity or Service Provided Here: Is your company ISO Certified? * Yes No Is your organization classified as a small business concern1? * Yes No If so, check all that apply: Small Business2 Woman-Owned Small Business3 Veteran-Owned Small Business4 Service Disabled Veteran-Owned Small Business5 Minority Owned Business6 Historically Black College or University7 Small Disadvantaged Business8 HUBZone Small Business9 Certification Numbers (if appl.):        The definitions provided below apply to businesses owned, operated and controlled by U.S. Citizens only.Businesses owned by non-U.S. citizens are classified as foreign-owned. “Small Business Concern” means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding, and qualified as a small business under the criteria in 13 CFR Part 121 (FAR 52-219-1). “Women-Owned Small Business Concern” means a small business concern which is at least 51% owned by one or more women or, in the case of any publicly owned business, at least 51% of the stock of which is owned by one or more women, and whose management and daily business operations are controlled by one or more women (FAR 52-219-1). “Veteran-Owned Small Business” means a small business concern not less than 51 percent of which is owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans, and whose management and daily business operations are controlled by one or more veterans (FAR 52-219-1). “Service Disabled Veteran-Owned Small Business” means a small business concern not less than 51 percent of which is owned by one or more Service-Disabled Veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more Service-Disabled Veterans, and whose management and daily business operations are controlled by one or more Service-Disabled Veterans or, in the case of a Service-Disabled Veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran (FAR 52-219-1). “Minority-Owned Business ” means a small businesses concern that is at least 51 percent unconditionally owned by one or more individuals who are both socially and economically disadvantaged or a publicly owned business that has at least 51 percent of its stock unconditionally owned by one or more socially and economically disadvantaged individuals.A minority-owned business is also a small business that is at least 51 percent unconditionally owned by an economically disadvantaged Indian Tribe or Native Hawaiian organization, or a publicly owned business that has at least 51 percent of its stock unconditionally owned by one of these entities, that has its management and daily business controlled by members of an economically disadvantaged Indian Tribe or Native Hawaiian Organization, and that meets the Small Business Administration regulations. Individuals who are Black Americans, Hispanics Americans, Native Americans, Asian-Pacific Americans, and Subcontinent-Asian Americans are considered socially and economically disadvantaged by the Small Business Administration. Hispanic Americans are U.S. citizens whose origins are in South American, Central America, Mexico, Cuba, the Dominican Republic, Puerto Rico, or the Iberian Peninsula including Portugal. Native Americans are American Indians, Eskimos, Aleuts and Native Hawaiians. Asian-Pacific Americans are U.S. citizens whose origins are in Japan, China, Philippines, Vietnam, Korea, Smaoa, Guam, U.S., Trust Territory of the Pacific Islands (Republic of Palau), Northern Mariana Islands, Loas, Kampuchea (Cambodia), Taiwan, Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Republic of the Marshall Islands, of the Federated States of Micronesia. Subcontinent Asian-Americans are U.S. citizens whose origins are in India, Pakistan, Bangladesh, Sri Lanka, Bhutan or Nepal. “Historically Black College or University ” means an accredited institution of higher education that was established before 1964; has a principal mission that was, and is, the education of Black Americans; and, as determined by the Secretary of Education, meets the regulations set forth by the U.S. Department of Education. Any non-profit research institution that was an integral part of a Historically Black College or University before November 14, 1986 is also included in this definition. “Small Disadvantaged Business” means a small business concern owned and controlled by socially and economically disadvantaged individuals that has received certification as a Small Disadvantaged Business in accordance with 13 CFR 124, Subpart B (FAR 52.219-8). “HUBZone Small Business” means a small business concern that appears on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration (FAR 52-219-3). Notice of Penalty We are required by Public Law 95-507 and Federal Regulations to identify the size and ownership status of our vendors. If you are unsure about your status, contact the nearest U.S. Small Business Administration Office (SBA) for guidance. Your answers to the Form may be used and relied upon by Black Box Networking Services in pursuing or administering contracts with the Federal Government or contracts with third parties who must comply with Federal Government regulations. You should respond to all questions on this Form fully and truthfully.   Under 15 U.S.C. 645(d), any person who misrepresents a firm’s status in order to obtain a contract to be awarded under the preference programs established pursuant to Section 8(a), 8(d), 9, or 15 of the Small Business Act, or any other provision of Federal law that specifically references Section 8(d) for a definition of program eligibility, shall (i) be punished by imposition of fine, imprisonment, or both; (ii) be subject to administrative remedies, including suspension and debarment; and (iii) be ineligible for participation in programs conducted under the authority of the Act (FAR 52.219-1). Certification By typing my name, I hereby certify that the information provided herein is true and correct to the best of my knowledge and belief. The foregoing information is valid with respect to all purchase orders, subcontracts and other supply agreements between Vendor and Black Box. Please type your full name here: