Supplier Certification - Ultralife Batteries

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SUPPLIER CERTIFICATION

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. Ultralife's family of brands and wholly-owned subsidiaries includes: ABLE, AMTI, McDowell Research, RedBlack Communications, RPS Power Systems, Stationary Power Services, U.S. Energy and Ultralife Batteries.

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: Manager of Small Business Subcontract Programs
FAX: (315) 210-6101
MAIL: Ultralife Corporation
2000 Technology Parkway
Newark, NY 14513

Detailed instructions will be supplied upon completion of this form.

SUPPLIER INFORMATION

Company *

Location *

Address
City	State/Province	Zip / Postal Code
Country

Phone Number *

Fax Number

Supplier's DUNS Number¹: *

Number of Employees: *

CAGE/FSCM Number²: *

Billing Address:

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

Billing Name *
Address
City	State/Province	Zip / Postal Code
Country

Name and Address of Parent Company:

Parent Name:
Parent's DUNS Number¹:
Address
City	State/Province	Zip / Postal Code
Country

BUSINESS INFORMATION (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	a corporation incorporated under the laws of the State of
		a limited liability company
		a sole proprietorship
		a partnership
		a nonprofit organization

(b)	if the supplier is a foreign entity, it operates as	a sole proprietorship
		a partnership
		a nonprofit organization
		a corporation registered for business in (country)

Check all applicable box(es) as described under FAR 19.001 Definitions and FAR 19.201 General Policy: *

	Foreign-Owned	Large Business (LB)
		Small Business (SB)
		Small Disadvantaged Business (SDB)
		Women-Owned Small Business (WOSB)
		Veteran-Owned Small Business (VOSB)
		Service-Disabled Veteran-Owned Small Business (SDVOSB)
		SBA-Certified HUBZONE Small Business (HUBZSB)
		Alaska Native Corporations (ANCs) & Indian Tribes, Not SBA Certified as SDB
		Alaska Native Corporations (ANCs) & Indian Tribes, Non-SB's
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)

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

Not Applicable No Yes

If Yes, provide effective date of HUBZone SBC Certification:

Provide NAICS CODE(S)³ that classify your type of business: *

Capabilities: List products, services, and special capabilities. *

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 difficutly ascertaining your size status, please refer to SBA's (Small Business Administration) website at www.sba.gov/size/ or contact your local SBA office.

CERTIFICATION

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.

Name: *

Title: *

E-mail Address: *

Website Address:

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 refered to as a Federal Supply Code for Manufacturers (FSCM) or Business Identification Number Cross-reference System (BINCS) Number.

³ NAICS CODE: This is a North American Industry Classification System Code, which was created to replace the SIC codes. It is a 6-digit value that classifies the type of business an organization offers.

For additional assistance, please contact
the Manager of Small Business Subcontract Programs at (315) 359-6292.

Ultralife Batteries brand - We. Are. Power.