The purpose of this form is to provide Stewart Title Supplier Diversity Program basic information about your business. It does not automatically put your name on the approved vendors' list, but it will assist in promoting your firm.

Please answer all questions or enter N/A (Non-applicable).

Company Information


Mailing Address (For Correspondence):




Facility Address (No P.O. Box please):





U.S. COMPANIES ONLY — Complete and return Internal Revenue Service Form W-9, Request for Taxpayer Identification Number and Certification.




See NAICS/SIC tables at http://www.sba.gov.

Business Type:

Affirmative Action Compliance

If your company employs more than 50 people, see http://www.dol.gov.

Has your company filed the required Affirmative Action programs required by the Secretary of Labor (per 41 CFR 60-1 and 60-2)?


Certification Regarding Debarment, Suspension, Proposed Debarment, and Other Responsibility Matters

Within the past three years, has the company or any of its principals, currently debarred, suspended or deemed ineligible for the award of contracts from a Federal agency?

Standard Business Classification

Per FAR 52.219–1 — See SBA size standards and classifications at http://www.sba.gov.

Standard Business Classification:

Small Business Classification:

* If you are a small business, but not SDB, Vet, SDV, WO or HUBZone, select “None of the above”.

* HUBZone — Provide a copy of your HUBZone certification with this form.

If Small Disadvantaged Business (SDB), select type:

8A Certified — Provide a copy of your certification from SBA with this form.

References

List three references for which you provided suppliers or services during the preceding 12 months.










Remittance address (If different from the mailing address)





Under 15 U.S.C. 645(d), any person who misrepresents its size status shall (1) be punished by a fine, imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act.




Standard Business Classification Definitions (Per Far 52.219-1, 19.001)

Small Business Concern:

A concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts and as further defined in FAR 19.102. Manufacturing and distributing firms: total employees do not exceed 500, 750, or 1000 as defined in FAR 19.102 and 13 CFR 121. Services: based on averaged annual volume of sales for the past three years per FAR 19.102.

Note: If firm total employment is between 500 and1,000 contact Small Business Administration for assistance for determining proper SIC code size standard.) Information on classifications and size standards may also be viewed on the SBA web site, see http://www.sba.gov.

Small Disadvantaged Business Concern:

As defined in FAR 19.102 and 13 CFR 124.1002 is a firm which meets the above criteria as a Small Business, and which is at least fifty-one percent unconditionally owned (as set forth in 13 CFR 124.105) by one or more socially or economically disadvantaged individuals; and whose management and daily business operations are controlled by one or more of such individuals.

Socially and economically disadvantaged individuals include:

  • Black Americans, Hispanic American, Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians), Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru), Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, The Maldives Islands, or Nepal). Individual/concerns, other than one of the preceding. See 13 CFR 124.109, 124.110 and 124.111 for ANCs, MHOs, or CDCs.
  • Historically Black Colleges-Universities and Minority Institutions (HBCU/MIs) are classified as Small Disadvantaged concerns.

Women-Owned Small Business Concern:

A firm which meets the above criteria as a Small Business and which is at least 51 percent owned by one or more women or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and whose management and daily business operations are controlled by one or more women.

HUBZone Small Business Concern:

A small business concern that appears on the List of Qualified HUBZone Small Business Concerns maintained by the SBA.

Small Business Concern Owned and Controlled by Veterans:

The term “small business concern owned and controlled by veterans” means a small business concern:

  • not less than 51 percent of which is owned by one or more veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and

Veteran — The term “veteran” has the meaning defined in 38 U.S.C. 101 (2).

Small Business Concern Owned and Controlled by Service-Disabled Veterans:

The term “small business concern owned and controlled by service-disabled-veterans” means a small business concern:

  • not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and
  • the management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a veteran with permanent and severe disability, the spouse or permanent caregiver of such a veteran.

Service Disabled Veteran — The term “service-disabled veteran” means a veteran with a disability that is service connected (as defined in section 101 (2) of title 38, United States Code).