Supplier Certification Form
 Request Date: 4/11/2021

requiredRequired Fields
Company Name
Unisys Vendor Number
Attention required    
Mailing Address required
City required
Zip Code

In order to comply with Public Law 95-507, Amendment to the Small Business Act, and various state and local government laws, Unisys must verify the business size and ownership of all suppliers. Please complete the following:

General Product Line, Service(s)
Chief Executive Officer
Annual Sales $ Telephone
Number of Employees FAX
NAICS Code(s) Email
For NAICS see: https://www.census.gov/epcd/www/naics.html
Duns required Tax Identification(TIN) required
Case Code

All companies that indicate the classifications Small Disadvantaged Business (SDB) and/or Historically Underutilized Business Zone (HUBZONE) must also be registered as such in the With The U.S. Small Business Administration .
Business Sizerequired Small Large  
Business Ownership - 51% Ownership & Control
  Woman-Owned Minority-Owned (Indicate Appropriate Category)
  Severely Handicapped   African American
  Veteran-Owned Business   Asian-Pacific American
  Service-Disabled Veteran Business Enterprise   Hispanic American
  Foreign Owned   Subcontinent Asian American
  Nonprofit   Native American (American Indians, Eskimos, Aleuts, Native Hawaiians)

Certifying Organizations:
  8(a) Certified Case #: SBA - 8a Graduation Date:     
  HUBZone (Historically Underutilized Business Zone)

SBA - HUB Entrance Date:
Exit Date:

  Disadvantage Business Enterprise Department of Transportation (DOT)
  Disabled Veteran Business Enterprise (DVBE)
  HBCU/MI (Historically Black College/University or Minority Educational Institution)  
  California OSMB-DVBE (California based service for Disabled Veteran Business Enterprise) California OSMB-DVBE,
Certification Exp:

Have you ever done work for Unisys Corporation?
Does your company perform at least half its operations outside the U.S. including those products supplied to Unisys?

Name required Title required
I hereby certify the above information is accurate to the best of my knowledge.

Notice: Under 15 U.S.C. 645(d), any person who misrepresents a firmís status as a small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to Sections 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references Section 8(d) for a definition of program eligibility, shall: 

(1) Be punished by imposition of a fine, imprisonment, or both;
(2) Be subject to administrative remedies including suspension and debarment; and
(3) Be ineligible for participation in programs conducted under the authority of the Act.