AFFIDAVIT OF CERTIFICATION BY SMALL LOCAL ... - WMATA.com

AFFIDAVIT OF CERTIFICATION BY SMALL BUSINESS page 2Firm Name:____________________________________List up to ten Authority Material Category Codes that represent the primary goods andservices your company sells (include the Authority alpha-numeric code and itscorresponding descriptive title, in words). The list can be found in Step 7 Categorizationof the vendor registration process or athttp://www.wmata.com/bus2bus/bidder_vendor/default.cfm1. 6.2. 7.3. 8.4. 9.5. 10.I understand that the Authority reserves the right to ask for tax records confirming grossreceipts at any time as well as certificates of incorporation issued by state or locality and thatthe information provided in this Affidavit will be kept confidential by the Authority.I agree to update my registration and location information in the Authority’s VendorRegistration System within thirty (30) calendar days of any such change (e.g., ownership,address, telephone number, e-mail address, etc).I acknowledge and agree that any misrepresentations in the Vendor Registration System oron this form or in records pertaining to a contract or subcontract with the Authority may begrounds for permanently terminating my business relationship with WMATA.Agreed to and Affirmed:_____________________ __________ _______ _____ (_ )_____ _Signature of Authorized Date E-mail Address Telephone NumberRepresentativeNOTARIZATIONI, _________________________________, a Notary Public in the____________________do hereby certify that_____________________________________,appeared before me and is known to me (or satisfactorily proven) to be the person whosename is subscribed to within this instrument. Subscribed and sworn before me this ____ dayof __________, 200__,SealNotary Public _ _ My Commission Expires on:This form shall be signed and returned by no later than December 31 st of every year to:Coordinator, Small Local Business Program, Office of Procurement and Materials, WashingtonMetropolitan Area Transit Authority, 600 Fifth Street, NW, Room 3B, Washington, DC 20001