Ultralife Corporation, as a U.S. Government Contractor, is required to comply with certain laws and Federal Acquisition Regulations (FAR) that require the collection and update of certifications from each of our suppliers and subcontractors. The procurement of material supplies or services for a U.S. Government contract requires compliance by prime contractors, subcontractors, and suppliers with various programs enacted into law, implemented by Executive Order and declared by Federal Regulations. Certifications on the specific requirements and your present state of compliance follow.

The following certifications are effective for the period of three years from the date of submission and received signature. If there is any change to your status under any of the following certifications during that period, you are required to inform Ultralife in writing promptly, within fifteen (15) days of the change in status.

Detailed instructions will be supplied upon completion of this form. Please complete all required sections; incomplete forms will not be considered.

PLEASE NOTE: Fields followed by a red * are REQUIRED. You will not be able to submit a page until completing all of the REQUIRED fields.

Your e-mail address and personal information are confidential and will never be sold or given to anyone. That is our promise to you.

Billing Address:
If your billing address is the same as above, check here.

Name and Address of Parent Company:


(Check all applicable)

The supplier, by checking the applicable box, represents that: *

(Check all applicable in either Section (a) OR Section (b).)

(a) it operates as
(b) if the supplier is a foreign entity, it operates as
A. Check all applicable box(es) as described under FAR 19.001 Definitions and FAR 19.201 General Policy: *

Misrepresentation of business size classification can result in the assessment of significant criminal and civil penalties and fines. (Reference Small Business Act 15 U.S.C. 645d)

B. If Supplier is a HUBZone Small Business Concern (HUBZone SBC), has supplier registered with Small Business Administration (SBA)? *


You may review the definitions for the above categories in the Federal Acquisition Regulation (FAR) 19.7 or 52.219-8 at If you experience difficulty ascertaining your size status, please refer to SBA’s (Small Business Administration) website at or contact your local SBA office.

I hereby acknowledge an awareness of the U.S. Government’s contracting and subcontracting programs and confirm the accuracy of the statements made above and that this certification applies to all Correspondence or Documentation received from Ultralife Corporation. This certification shall apply to all Requests for Quotations, Purchase Orders, Contracts or Subcontracts received from Ultralife. Furthermore, I am responsible for notifying Ultralife of any changes in status affecting this certification.


I Accept Electronic Signature. The offeror verifies by submission of this document that the representations and certifications shown above are current, accurate, and complete as of this dated executed.

Please Enter the Words Below

If you choose not to submit electronically, you must print all pages, manually sign the form, and send via fax or email to the address below:

Attn: Small Business Subcontract Programs
Ultralife Corporation
2000 Technology Parkway
Newark, NY 14513
FAX: (315) 331-7800

1 DUNS Identification Number: This is a Dun and Bradstreet (DUN) unique nine-digit identification number used by federal and commercial entities describing value-added data associated with business entities.

2 CAGE Number: This is a Commercial and Government Entity (CAGE) Code, which is assigned by the Department of Defense. It is a 5-character alphanumeric value with no spaces. The CAGE number might also be referred to as a Federal Supply Code for Manufacturers (FSCM) or Business Identification Number Cross-reference System (BINCS) Number.


For assistance, please contact the Small Business Subcontracting Program at (315) 332-7100.