UI Vendor #:

Clear Form
03.12.08
Print Form
UI Vendor #:
INSTRUCTIONS: Please provide all information (typed or printed) as requested in the spaces provided. The IRS
requires that you provide information which will allow us to complete 1099 reporting. Unless you provide a
correct Taxpayer Identification Number and 1099 reporting address, your payments may be subject to 31%
withholding.
Indvidual Name:
Company or Business Name:
(Sole Proprietors see below)
Axibase Corporation
FEIN
Federal ID or SSN: 20-2148705
1099
19925 Stevens Creek Blvd
Address:
Order to
19925 Stevens Creek Blvd
Address:
RFQ
19925 Stevens Creek Blvd
Address:
Remit to
19925 Stevens Creek Blvd
Address:
SSN
City: Cupertino
St: CA
Zip: 95014
City: Cupertino
St: CA
Zip: 95014
City: Cupertino
St: CA
Zip: 95014
City: Cupertino
St: CA
Zip: 95014
Website: www.axibase.com
Purchase Order Email: [email protected]
Note: Email address should be monitored regularly to prevent delayed
orders and adequate storage space to prevent email rejection.
Order Contact: Sergei Rodionov
Phone: +1 (408) 973-7897
Toll Free Phone:
Remit Contact: Sergei Rodionov
Phone: +1 (408) 973-7897
Order to Fax:
Sales Contact: Sergei Rodionov
Phone: +1 (408) 973-7897
A/R Fax:
Management Contact: Sergei Rodionov
Phone: +1 (408) 973-7897
Fax:
Type of Organization (choose all that apply)
Corporation
Date Incorporated 04/2004
Non-Profit
Sole Proprietor
Payment Terms:
UI Requests 30 days
Does your business accept:
Which State:
DE
Partnership
Other (Specify):
Credit Cards?
Yes
No
ACH? (Automated Clearing House)
Yes
No
(If "Yes" is checked, then the "Authorization for Electronic
Vendor Payments" section on page 3 must be filled out.)
Net + 30
Type of Business (choose all that apply)
Construction Concern
Entertainment
Tax Exempt
Services you provide:
Buildings 07
Computing Services 07
Consultant 07
Dealer with Inventory Stock
Manufacturer or Producer
Other Software Vendor
Land Improvements 07
Laundry/Dry Cleaning 07
Medical/Dental 06
Dealer without Inventory Stock
Professionally Licensed
Professional & Non/Med 07
Professional Attorney/Legal 14
Publication/Copy 07
Rental & Leases 01
Repair/Maint-Buildings & Land 07
Repair Maint-Equipment 07
Distributor
Service Establishment
Royalties & Copyrights 02
Do not provide any services listed
Type of Operation (choose all that apply)
Iowa Small Business (See page 2)
Certified Iowa Targeted Small Business
(Submit a copy of your Iowa Dept. of Inspections
Appeals certification (See pg 2 for definition)
Iowa Targeted Small Business (See page 2)
Federal Small Business
Veteran Owned
(As defined by federal law. (See page 2 or www.ccr.gov)
(51% or more owned and managed by Veterans
Women Owned Concern
Minority or Disadvantaged Owned Concern
(51% or more owned and managed by women)
Disabled Owned
(51% or more owned and managed by disabled persons)
Helpful Hints
(51% or more owned and managed by minority persons
If applicable:
African American
Hispanic American
Disabled
Veteran
Asian American
Native American
• TAXPAYER IDENTIFICATION NUMBER {Federal Employee Identification Number (FEIN) or Social Security Number (SSN)} is 9 numerical digits and
each number has a standard format:
FEIN XX-XXXXXXX
SSN XXX-XX-XXXX
• If you use a SSN, the IRS requires that you include the name of the individual whose SSN has been entered.
• The IRS requires the University of Iowa to report 1099 information. This includes non-profit organizations and government agencies. List your Taxpayer Identification
Number (as recorded with the IRS). Please note this form does not require that you list your tax exempt number or state identification number.
• Sole Proprietors: Must enter your individual name (as shown on your Social Security card) on the Individual Name line. You may enter your business or "doing business as"
name on the Business Name line. For the Taxpayer Identification Number, enter either your Social Security Number or the Federal Employer Identification Number of the
business (sole proprietorship).
• Business Name: Enter the name of the entity as it is listed with the IRS on the Form SS-4, Application for Employer Identification Number. This name should be consistent
with the name used on your other tax returns.
Page 1-UI Vendor Application/Revised 6/2007
Page 2-UI Vendor Application/Revised 6/2007
Federal Small Business Definitions
The Federal Government, through Section 129 of Public Law 100-590, Small Business Administration (SBA) Reauthorization Act of 1988, has provided the
following guidelines for certification of small businesses, which will facilitate participation in federal programs and bidding for government-funded contracts.
• Small Business: a business concern that is organized for profit, fewer than 500 employees, including affiliates, is independently owned and operated, is not
dominant in the field of operation, and meets size standards as prescribed by SBA (13 CFR Part 121).
• Sole Proprietors: a sole proprietorship means "one owner". The owner assumes all responsibilities for the business, including assets and liabilities. Business
income is taxed as personal income. Most small businesses operate as sole proprietorships, this being the simplest form of organization and allowing the
single owner to have sole control and responsibility.
• Woman-Owned Business: a business that is (1) at least 51 percent owned by a woman or women, or, in the case of publicly owned business at least 51
percent of the stock is owned by one or more women; and (2) whose daily business operations are managed and directed by one or more of the women
owners. "Operate" means actively involved in the day to day management.
• Minority-Owned Business: a business that is (1) at least 51 percent owned by one or more minority individuals, or, in the case of publicly owned business at
least 51 percent of the stock is owned by one or more minority individuals; and (2) whose daily business operations are managed and directed by one or more
minority owners. "Operate" means actively involved in the day to day management.
• Minorities include the groups with the following ethnic origins: African, Asian Pacific, Asian Subcontinent, Hispanic, Native Alaskan, Native American, and
Native Hawaiian.
• Disadvantaged Business: a business that is (1) at least 51 percent owned by disadvantaged individuals, or, in the case of publicly owned business at least 51
percent of the stock is owned by one or more disadvantaged individuals; and (2) whose daily business operations are managed and directed by one or more
disadvantaged owners. "Operate" means actively involved in the day to day management. Disadvantaged individuals include Black Americans, Hispanic
Americans, Asian Americans, and other minorities, or individuals found to be disadvantaged by the Small Business Administration pursuant to Section 8 of the
Small Business Reauthorization Act.
• Iowa Small Business: a business concern as defined by Iowa Law (average annual gross income of less than 3 million over the last 3 years)
For more information about the federal Small Business programs please contact your local Small Business Administration (SBA) office. www.sba.gov
Targeted Small Business Definitions
The Iowa Legislature, through House File 2403, has provided guidelines for certification of "Iowa Targeted Small Businesses" (TSB's) and has established
procurement goals for state agencies to procure goods and services from TSB's.
• "Targeted Small Business" means a small business where the principal place of business, production, or manufacture occurs in Iowa, which is fifty one
percent (51%) owned, operated, and actively managed by one or more women, minority persons, or persons with a disability provided the business meets all
of the following requirements: (1) is located in Iowa; (2) is operated for profit; (3) has an annual gross income of less than three million dollars computed as an
average of the three preceding fiscal years.
• "Minority Person" means a person who is: Black, Hispanic, Asian or Pacific Islander, American Indian, or Alaskan Native American.
Product/Services Categories
Please review the list of products and services in this section. Check any that apply.
Communication/Telecom.
Automotive/Trucks
Athletic
Awards & Trophies
Equipment
Clothing/Uniforms
Mass Transit/Buses
Supplies
Parts Supplies
Training Equipment
Rentals
Repair Service
Tractors/Lawn Equip.
Trailers
Vehicles
Construction
Carpentry
Construction Materials
Building Materials
A/V Equipment
Computers.
Mainframe Equipment
Cellular Products/Svcs.
Micro Computers
Phone System Equipment
Parts/Supplies
Phone System Service
Programming & Analysis
Repair Service
Software
Phone Parts/Supplies
Radio System Supplies
Sound Equipment
Television-Commercial
Television Equipment
Contractors/Supplies
Boilers-Repair/Maint.
Heating/A.C.
Plumbing
Furniture & Fixtures
Auditorium/Stadium Seating
Concrete Work
Concrete
Construction
Equipment & Rentals
Electrical
Electrical Supplies
Floor Coverings
Environmental
Lumber
Installation Service
General Contractor
Plumbing
Library Furniture
Masonry
Roofing
Office Furniture
Design Service
Dormitory Furniture
Window Coverings
Roofing
Lab/Medical
Dental
Drugs
Equipment/Supplies
Furniture
X-Ray
Office Products
Office Equipment
Copiers/Supplies
Envelopes
Paper/Printing Supplies
Printers/Scanners
Temporary Personnel
Lab/Scientific
Animals
Miscellaneous & Other Equipment
Advertising
Analytic Svcs./Equipment
Cleaning Equip./Supplies
Drugs/Pharmaceuticals
Equipment/Supplies
Chemicals
Digital Cameras
Professional
Architecture
Art Photography
Consulting
Engineering
Graphic Design
Printing/Engraving
Publications
Web Design
Elevators Maint/Repair
Food Products/Services
Laundry Equip./Supplies
Refrigeration Equipment
Repair/Maint. Service
Theatrical
Travel Services
Hauling Disposal
Scientific
Analytical Equipment
General Equipment
Chemicals
Plastic/Glassware
Supplies
Other Products or Services
(please specify)
Software maintenance
Page 3-UI Vendor Application/Revised 6/2007
Conflict of Interest Policy (REQUIRED)
The Board of Regents and the Iowa Code policies govern business transactions involving conflict of interest situations and
relationships between employees and vendors. The University of Iowa has established procedures in accordance with the Board of
Regents and Iowa Code policies on conflict of interest for individuals participating in purchasing decision making.
Please see www.uiowa.edu/~purchase/purchase/P_vendors/conflict_of_interest.htm from more information.
Yes
Does any Officer, Director, Owner or Partner in this company have a relationship with the University of Iowa?
No
The types of relationships include: 1. A spouse/partner or minor child is employed by the University of Iowa
2. A financial relationship with a University of Iowa employee
3. A personal relationship with a University of Iowa employee
If yes, please state the NAME and RELATIONSHIP to individual:
Does any Officer, Director, Owner or Partner in this company hold a position at any State of Iowa Regent institution or any State of Iowa
government department or agency?*
Yes
No
If yes, please state the NAME and RELATIONSHIP to individual:
*State of Iowa Regent Institutions include: University of Iowa, Iowa State University, University of Northern Iowa, Iowa School for the Deaf, Iowa
Braille and Sight Saving School, and State Board of Regents
Vendor Application Verification (Signature Required)
I verify neither I or my business has ever been excluded from doing business with any federally or state funded health care programs and I (we) have never beendisbarred or
suspended from doing business under Executive Order 12549, Debarment and Suspension, 13 CFP Part 145.
The undersigned certifies that the information contained herein is correct. I understand that misrepresentation may be cause for removal from the qualifiedvendor list and
any other penalties allowed by law. Further, I affirm that this company's employment practices do not discriminate because of age, race, creed,color, sex, national origin,
religion, or disability. I also affirm that the undersigned company is not currently debarred from bidding by any State of Iowa or Federal agency and has not been convicted
of any violations of the Federal Anti-Kickback Enforcement Act.
Name of individual who prepared this form: Sergei Rodionov
Authorized Signature:
Name (printed): Sergei Rodionov
Title: CEO
Phone: 408.973.7897
Date: Dec 3, 2008
Authorization for Electronic Vendor Payments (ACH) (Signature Required)
We can electronically transfer payments to the financial institution of your choice, anywhere in the United States. Please complete the information below authorizing the
ACH payment process between The University of Iowa and your company. This authority remains in effect until written notice is given to cancel/change/stop the service.
Please start depositing payments and reimbursements for the above vendor to Checking effective:
Complete the following or attach a preprinted, voided check which provides this information to this form.
Bank Name: Silicon Valley Bank
Account #:
Bank Routing #: 121140399
3300480234
Signature (for ACH Payments):
Request Vendor Web AP Access (Signature and Email Required)
This is for viewing and checking invoices for payment when ACH has been established.
I hearby request access to the University of Iowa Vendor AP Access Application. I understand that my access is limited to my company's transactions; I will not
have access to any other vendor's transaction data. I understand that the information available to me through this access ID is the property of the University of
Iowa and as such must be treated with confidentiality and may be used for University business only.
Name (Printed): Sergei Rodionov
Signature (for Web Access):
Phone: 408.973.7897
email: [email protected]
Office Conflict of Interest Date Approved
Use
Only
Date Rejected
TSB Certification
Requester
Requester Address
Date Sent