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. Headquartered in Newark, New York, the company's business segments include: Battery & Energy Products, Communication Systems and Energy Services. Ultralife has operations in North America, Europe and Asia.
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 are contained in the following sections. Please review and complete all sections. THERE ARE NO EXCEPTIONS FOR ANY SECTION.
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.
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.
Please print, SIGN, and fax or mail the completed form to one of the following:
Attn: Small Business Subcontract Programs
FAX: (315) 331-7800
MAIL: Ultralife Corporation
2000 Technology Parkway
Newark, NY 14513
Detailed instructions will be supplied upon completion of this form.
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).)
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 www.arnet.gov/far/. If you experience difficulty ascertaining your size status, please refer to SBA’s (Small Business Administration) website at www.sba.gov/size/ 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.
ELECTRONIC SIGNATURE AGREEMENT
REFUSAL OF ELECTRONIC SIGNATURE AGREEMENT
If you choose not to electronically sign this form you must print all pages, manually sign the form and fax to (315) 331-7800
Please Enter the Words Below
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.