VENDOR ADMINISTRATION AND 1099 ISSUANCE FORM

Name:

Address: 

City:    State:   Zip Code:

Taxpayer I.D. Number:
(TIN, SS, or EIN number)

Attorney Representative

All non-individual claimants must be represented by an attorney who is a member in good standing of the North Carolina State Bar and who has been admitted to practice before the United States District Court

Name:

Address: 

City:    State:   Zip Code:

Telephone:    Email Address:

Vendor Representations:

      This vendor hereby represents that it   IS   or    IS NOT    a minority-owned business concern
      This vendor hereby represents that it   IS   or    IS NOT    a women-owned business concern
      Vendor Classification is:        Corporation,            Partnership,            Sole Proprietorship

Information provided by:

Printed Name, Position/Title                                                                                         Date
     

______________________________________________________________________________________
 Checking this box constitutes signing this document. (Please retain signed copy for your records)
   Penalty for making a false statement: Fine of up to $500,000 imprisonment for up to 5 years, or
   both. 18 U.S.C. §§ 152 and 3571.
______________________________________________________________________________________

Please make sure you have filled in all the details and print this form before submitting it

Definitions - as used for the purpose of completing this form.

Minority-owned business concern means a business concern –

(1) which is at least 51 percent owned by one or more individuals within one or more of the categories listed below; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more individuals within one or more of the categories listed below; and (2) whose management and daily business operations are controlled by one or more individuals within one or more of the categories listed below.

•      Black American
•      Hispanic American
•      Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians)
•      Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru)
• Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal)

Women-owned business concern means a business concern –

1. That is at least 51 percent owned by one or more women; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and
2. whose management and daily business operations are controlled by one or more women.