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					                                      New Jersey Public Law 1977 C.33
 THIS ENCLOSURE MUST BE COMPLETED, SIGNED, AND RETURNED WITH THE PROPOSAL OR YOUR
 PROPOSAL WILL BE INVALID.

 Pursuant to N.J.P.L. 1977, Chapter 33, the vendor must provide a complete list of names and address of all persons
 who fall into any of the following categories. (If additional space is required, use a separate sheet and attach)

 1. If a Vendor is a Corporation, Vendor hereby certifies that the following is a complete list of the names of
 stockholders who own 10% or more of its stock, of any class:
                                                                 Addresses
 Names




 Name of Corporation:

 Authorized Representative (Print):

 Signature and Date:

 2. If the Vendor is a Partnership, Vendor hereby certifies that the following is a list of all partners in Vendor who
 own 10% or greater interest in the assets, profit, or cash flow of Vendor:

 Names                                                            Addresses




 Name of Partnership:

 Authorized Representative (Print):

 Signature and Date:

 3. If Vendor is either a Partnership or a Corporation, and one or more stockholder or partner is itself a Corporation
 or Partnership, the Vendor must list the stockholders holding 10% or more of that corporation or the individual
 partners owning a 10% or greater interest in that partnership, as the case may be.

 Names                                  Addresses                                            Name of
                                                                                             Corporation/Partnership
                                                                                             (Stock/Interest In)




 Submitted By: (Name of Firm)

 Authorized Representative (Print):

 Signature and Date:
                                                         Page 1

PO 64      Revised July 8, 2002
                                        New Jersey Public Law 1977 C.33

   4. If Vendor has previously provided Rutgers - The State University with the information required by N.J.P.L. 1977
   C.33 on this form, and there has been no change of ownership of Vendor since such information was provided, or
   the vendor is a sole proprietorship, the foregoing is not required, but THE VENDOR MUST SIGN BELOW FOR
   CERTIFICATION:

   Purchase Order or RFQ Number:

   Date: (If Applicable)

   Name of Firm:

   Authorized Representative (Print):

   Signature and Date:




                                                        Page 2
PO 64      Revised July 8, 2002

				
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