B.1b - Enclosure B. AMS-Form-050

ANNUAL REPRESENTATIONS & CERTIFICATIONS

AMS-FORM-050

Offeror: Brookhaven National Laboratory (BNL/BSA) must gather and maintain certain registration data from all Offerors. BSA must also gather additional representations and certifications from Offerors' Authorized Representative who do currently (or want to) provide goods or services in support of a U.S. Government (USG) Contract. This form is designed to efficiently and effectively gather both the required registration information and, when applicable, the additional representations and certifications. (1) All Offerors, regardless of business size, solicitation type, or dollar amount, must complete Section A.1. and Section C in completely by an Authorized Representative.
(a) In addition to Section A.1. and Section C, all Small Business Offerors must also complete Section A.2; and (2) Any Offerors who do (or want to) provide BSA with goods or services in support of a USG contract must also complete Section B. Note: Some of the certifications and representations herein are similar to those solicited via the USG’s representations and certifications database (e.g., SAM.gov). Additionally, certain other solicitation-specific and procurement-specific policies and procedures may require additional representations and certifications from Offeror.

Section A.1.: Business Information
A.1. Part I: Business Name, Address, and Contact Info (Note: Business Name, DBA/Division, and Address should match W9 or W8 info) Business Name:

Remit Information (complete only if different from business info in left column)

Doing Business As (DBA) or Division (if applicable)
Business Address (Number, Street, Apt. or Suite):

Remit to Address (PO Box or Street Address):

City, State/Province/Region:

City, State/Province/Region:

Country:

Zip+4 or Postal Code:

Country:

Zip+4 or Postal Code:

Telephone:

Email:

Telephone:

Email:

A.1. Part II: Additional Business Information
(a) Enter Offeror's Unique Entity Identifier Number (if known) as provided by SAM.gov: Offeror is

(is not

) registered with the U.S. Government’s or any successor USG database; e.g., the System

for Award Management at www.SAM.gov).
(b) Enter Offeror's main (parent) NAICS Code:
(c) Provide Offeror’s physical business location information (complete only if different from Business Address entered in Section A.1, Part I): Physical Location Address (Number, Street, Apt. or Suite): City, State/Province/Region:
Country:

Zip+4 or Postal Code:

Telephone:

Email:

AMS-Form-050 Rev. 1.0 - 09/2023