Common use of FED Clause in Contracts

FED. EMPLOYER IDENTIFICATION NO.     -               (Employer Identification #) COMPLETE THIS SECTION WITH CHECK REMITTANCE ADDRESS AS IT APPEARS ON INVOICES: REMIT TO ADDRESS: STREET / PO BOX:   Participation in this section is voluntary. You are not required to complete this section to become a registered vendor. The information below will in no way affect the vendor registration process and its sole purpose is to collect statistical data on those vendors doing business with NCDOT. If you choose to participate, circle the answer that best fits your firm’s group definition. What is your firm’s ethnicity? (Prefer Not To Answer, African American, Native American, Caucasian American, Asian American, Hispanic American, Asian-Indian American, Other:   ) What is your firm’s gender? (Prefer Not to Answer,Male, Female) Disabled-Owned Business? (Prefer Not to Answer, Yes, No) Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. person (including a U.S. resident alien).           SIGNATURE (Typed or DocuSigned signatures will not be accepted) DATE PHONE NUMBER     EMAIL Corporate Status (Check only one.) License Number: __________________ Dated: _______________ ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Name and title of person authorized to execute this agreement ________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____ Name of individual authorized to answer questions concerning the information contained herein: Name ___________________________________ Telephone No. __(_____)________________________ Name, address, and telephone number of designated management person to contact after award of contract: __________________________________________________________________________________________ Telephone Numbers: (Please put all numbers that are available to you.) Office: ___________________ Cell: _____________________ Pager: ___________________ Corporate Status (Check only one.) ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____

FED. EMPLOYER IDENTIFICATION NO.     -               (Employer Identification #) COMPLETE THIS SECTION WITH CHECK REMITTANCE ADDRESS AS IT APPEARS ON INVOICES: REMIT TO ADDRESS: STREET / PO BOX:   CITY, STATE, ZIP:   Participation in this section is voluntary. You are not required to complete this section to become a registered vendor. The information below will in no way affect the vendor registration process and its sole purpose is to collect statistical data on those vendors doing business with NCDOT. If you choose to participate, circle the answer that best fits your firm’s group definition. What is your firm’s ethnicity? (Prefer Not To Answer, African American, Native American, Caucasian American, Asian American, Hispanic American, Asian-Indian American, Other:   ) What is your firm’s gender? (Prefer Not to Answer,Male, Female) Disabled-Owned Business? (Prefer Not to Answer, Yes, No) Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. person (including a U.S. resident alien).           SIGNATURE (Typed or DocuSigned signatures will not be accepted) DATE PHONE NUMBER     EMAIL Corporate Status (Check only one.) License Number: __________________ Dated: _______________ ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Name and title of person authorized to execute this agreement ________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____ Name of individual authorized to answer questions concerning the information contained herein: Name ___________________________________ Telephone No. __(_____)________________________ Name, address, and telephone number of designated management person to contact after award of contract: __________________________________________________________________________________________ Telephone Numbers: (Please put all numbers that are available to you.) Office: ___________________ Cell: _____________________ Pager: ___________________ Corporate Status (Check only one.) ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____