California Institute of Technology ♦ Supplier Management MC 103-6 ♦ Pasadena, CA 91125
Please complete and return the Internal Revenue Service (IRS) Form W-9 below and the supplemental payee information
sheet on the back of this letter. According to federal regulations, a completed IRS Form W9 is required of all our payment
recipients. The purpose of the IRS Form W-9 is to provide us with your correct taxpayer identification number (TIN). We
realize you may not be subject to tax reporting due to your business status. However, in order to make this determination we
must have an IRS Form W-9 on file. The supplemental payee information is needed to verify your most recent mailing
address and other pertinent payment information.
Small Business Utilization
As a recipient of federal funds, we are required to assess the volume of business we transact with suppliers that are
classified as Small Business, Historically Black Colleges/Universities, HUBZone Small Business, Small Disadvantaged
Business, Women Owned Small Business, Service Disabled Veteran Owned and Veteran Owned Small Business
enterprises. In order to provide that information, we are required to maintain a completed Supplier Profile form for each
supplier/consultant that is categorized as one of the above. If you classify as a Small Business (less than 500 employees),
please complete the Supplier Profile Form in addition to the IRS Form W-9.
∗∗∗∗∗∗∗∗∗∗ Due within 10 days of receipt ∗∗∗∗∗∗∗∗∗∗
Use the enclosed envelope to return your completed forms, or
Fax to Supplier Management at (626)666-3928 (please fax both sides of this form)
Primary contact, Rebekah Sims at (626)395-2674 or alternate contact, Hotline at (626)395-8900
Exemption: If exempt from reporting, check here AND circle your qualifying exemption reason below:
1. Corporation, 2. Tax Exempt 3. The United States or 4. A state, the District of 5. A foreign government
excludes medical, Charity under any of its agencies Columbia, a possession or any of its political
healthcare payments, or 501(a) (includes or instrumentalities. of the United States, or any subdivisions.
payments for legal services. 501(c) (3), or IRA. of their political subdivisions.
Part II Certification: I am a U.S. person (including a resident alien).
Person completing this form: _________________________________________ Title: ____________________________
Signature: ________________________________________________________ Date: ____________________________
Tax correspondence address: __________________________________________________________________________
Phone: (________) ________________________________
W9 Form/September 2005 Supplier #: ________
California Institute of Technology ♦ Supplier Management MC 103-6 ♦ Pasadena, CA 91125
Payee Information:
Payee Name:
Is the above payee doing business under another name? Yes No
If yes, please list business name:
Customer #: (Please specify the customer number your business assigns Caltech)
Caltech delivers Purchase Orders (PO) electronically to a fax or email address
Please choose your preferred method of PO delivery: Fax Email
Address:
Phone: ( ) Fax: ( )
Email Address: Website:
Make checks payable to:
Remit Address:
Is your company registered to do business within the State of California: Yes No
Resale Permit Number:
Primary NAICS Code (6-digits): (For more information see http://www.census.gov/epcd/www/naics.html)
Does your business accept MasterCard: Yes No
Contact Name (first and last):
Contact Phone: Contact Email:
Large Business
Small Business (please complete Supplier Profile Form attached)
******** Due within 10 days of receipt ********
W9 Form/September 2005
California Institute of Technology ♦ Small Business Program ♦ MC 103-6 ♦ Pasadena, CA 91125
Supplier Profile Form
The California Institute of Technology is continuing to build its Small Business Resource Directory consisting of small
businesses, which it contacts through its outreach program. If you wish to have your business added to our database and listed
in our online resource directory, please complete both sides of this form and return it to the address listed above or you may fax
both sides of this form to (626)666-3928, Attn: Small Business Program. If you have any questions, please contact Genger
Richmond at (626)395-2895 or Rebekah Sims at (626)395-2674.
If you require assistance in determining the size and status of your organization or your primary North American Industry
Classification System (NAICS) code, please contact the United States Small Business Administration (SBA) at 1-800-U-ASK-
SBA. Further information and definitions are also available on the SBA’s website: www.sba.gov.
Name:
Doing Business As (dba):
Address:
City: State: Zip:
Phone: ( ) Fax: ( )
Website: Email:
Business Classification Business Concern (check all that apply)
Are you classified as a small business? Historically Black College/University
or Minority Institution
Yes No
HUBZone Small Business (please attach copy of SBA certification)
Number of Employees: Minority Owned Business
Annual Sales: $ Small Disadvantaged Business (please attach copy of SBA certification)
Primary NAICS Code: Service Disabled Veteran Owned Small Business
Veteran Owned Small Business
Woman Owned Business
Penalties and Remedies for Misrepresentation of Business Status
Under 15 U.S.C 645(d), CFR 121 any person who misrepresents a firm’s status as a small, small disadvantaged, women-owned, or HUBZone
small business concern in order to obtain a contract to be awarded under 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 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.
Supplier Profile Form/September 2005 Turn page over
California Institute of Technology ♦ Small Business Program ♦ MC 103-6 ♦ Pasadena, CA 91125
Product/Services Category List:
Our Small Business Resource Directory sorts listings using the categories listed below.
Please check all that apply:
Accommodations and Food Service/Supplies Industrial Supplies
Animal Related Janitorial/Cleaning Related
Apparel Laboratory Related
Audio Visual Related Office Supplies
Automotive Repair and/or Maintenance/Supplies Print/Copy Services and/or Supplies
Business Machines Professional Services
Computer Related Rentals
Construction – Repair and/or Maintenance Research Related
Consulting Safety/Environmental Related
Electrical/Electronic/Mechanical Related Specialty Advertising/Gifts
Entertainment Related Telecommunication
Gases Travel Related
Health Care Related
Describe the products and/or services your company provides:
List any higher education or research facility you have done business with:
Certification:
I CERTIFY THAT: 1) the business size, and/or 2) the characteristics of the firm’s ownership are accurately reflected as indicated
above; 3) all information supplied herein (including all attachments) is correct; and 4) that neither the applicant nor any person or
concern in any connection with the applicant as principal or officer, so far as known, is debarred or otherwise declared ineligible
by any agency of the Federal and State Government from making offers for furnishing materials, supplies or services to the
Government or any agency thereof.
Signature (Company Official):
Type or Print Name: Date: Title:
If certifying as “Small”, is firm registered in CCR? Yes No
Is your firm certified by SBA as “HUBZone” ? Yes No
Is your firm certified by SBA as “SDB” ? Yes No Exit Date:
Is your company certified by a Federal or State agency as a minority owned business enterprise (MBE)? Yes No
Is your company certified by a Federal or State agency as a woman owned business enterprise (WBE)? Yes No
Information on CCR (Central Contractor Registration) is available at www.ccr.gov
Supplier Profile Form/September 2005