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Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

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Page 1: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 1 of 13

Vendor Qualification and Renewal Form

Vendor Name:

_________________________________________________________________________________________________ (as appears on IRS Form W-9)

Issued By :

_________________________________________________________________________________________________ (Fairlead Representative)

Attachments: 1.) 00_Fairlead PO Terms _ Conditions-v2016-05-03.pdf

2.) 00_Fairlead Conflict Minerals Policy.pdf

Purpose: To convey Fairlead requirements for vendors and collect information used to qualify prospective vendors or evaluate existing vendors for renewal of Active status. Information provided in this questionnaire may be independently verified by Fairlead personnel, but will remain confidential and proprietary information within Fairlead. In order to become eligible for awards in support of Fairlead government contracts and subcontracts, Fairlead may request to conduct a quality system audit. Please complete all sections of the questionnaire if any section does not apply please mark N/A. Return Information Please return the completed Vendor Qualification and Renewal Form via: Mail: Fairlead Attn: Supply Chain

650 Chautauqua Ave. Portsmouth, VA 23707

email: [email protected]

Section 1. Qualification Type

New Vendor Qualification (Begin in Section 3) Active Vendor Renewal (Begin in Section 2)

Vendor ID: ______________________________

Last Qualification Date:____________________

Page 2: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 2 of 13

Vendor Qualification and Renewal Form

Section 2. Renewal Instructions and Acknowledgment

Fairlead Integrated allows Vendors to make an incremental response to vendor data if the vendor is already approved and in Active status. Vendors will be asked to submit renewal forms on an annual basis.

• Review Sections 3 – 6 for any information that may have changed since your last qualification date. Update any information that has changed. Provide current copies of any certifications you have previously listed or added. Fields marked N/A (or similar) indicate no change of information.

• Sections 7 – 12 are required for renewal • Signing the renewal form certifies that the information provided or indicating no change is true and

accurate.

I have read and acknowledge instructions for renewal.

Page 3: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 3 of 13

Vendor Qualification and Renewal Form

Section 3. Contact Information

CONTACT 1 (Sales/ Order) CONTACT 2 (Payment)

Name / Job Title:

Business Phone:

Business Fax:

Mobile:

Email Address:

CONTACT 3 (Quality Assurance) CONTACT 4

Name Job Title:

Business Phone:

Business Fax:

Mobile:

Email Address:

For Orders and Correspondence

For Payment

Company Address

Address Line 2

City

State

Zip

Website

DUNS #

Cage Code

NAICS Code

Page 4: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 4 of 13

Vendor Qualification and Renewal Form

Section 4. Business Classification

Large Small Non-Profit Foreign/Other

Type of Business:

Sole Proprietor Partnership Corporation LLC

If publicly traded please provide ticker symbol:___________________

If Small Business, check all that apply: Woman Owned

Disadvantaged (including minority owned)

HUBZONE

Veteran Owned

Service Disabled Veteran Owned

Other Business Names: List any trade name, abbreviation or other “Doing Business As” name (other than the vendor name on this form) used to conduct business within the last 10 years.

_________________________________________ _______________________________________________

_________________________________________ _______________________________________________

_________________________________________ _______________________________________________

Section 5. Scope of Qualifications

1. Please identify the services and/or products that this company provides.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

2. Does this company provide only commercial services or products, as defined by FAR Part 2.101?

(Services and Products that are not to a MIL-SPEC or NAVSEA Standard or drawing)

Yes No

Page 5: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 5 of 13

Vendor Qualification and Renewal Form

3. Are there any special processes and/or standards followed in the manufacture of your products? Please identify these qualifications, procedures or standards below. Provide attachments if necessary.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

4. If providing services/ products using a Fairlead supplied document, describe your configuration management procedures? Or attach a copy of your procedure and/or flowchart.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

5. List accreditations or certifications of the business and attach copies of the certificates or accreditations with this completed form).

(Examples: Quality System Certification, Qualifications for Special Process)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

6. If you do not have any accreditations or certifications relative to the product or service you provide is there documentation in place for the following Quality System major elements?

QA Program Yes No Org Chart Yes No Personnel qualification and training Yes No Work procedures Yes No Procurement Systems Yes No Subcontractor evaluations Yes No Equipment calibration and maintenance Yes No Material Traceability Yes No Corrective action process Yes No Shipping and storage Yes No Internal and external audits Yes No

Page 6: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 6 of 13

Vendor Qualification and Renewal Form

7. If you are an Authorized Distributor or Dealer for an OEM, list the OEMs and attach copies of the Authorized Distributor letter of certificates.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

8. Has this company performed work in support of a government contract, or does this company currently hold a government contract?

Yes No

If Yes, please provide active or recent contract number(s).

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Section 6. General Registrations

System for Award Management (SAM.gov) Yes No

Counterfeit Reporting and Prevention

Government - Industry Data Exchange Program (GIDEP) Yes No

GIDEP POC: ______________________________________________________

GIDEP Identification Number:_________________________________________

Electronic Resellers Association International (ERAI) Yes No

Page 7: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 7 of 13

Vendor Qualification and Renewal Form

Section 7. ITAR Vendor Export Compliance Certification

Fairlead requires that its suppliers certify certain information necessary to ensure compliance with U.S. Government export control laws and regulations. Adherence to this requirement is necessary before Fairlead will place, or continue to place, any orders, participate in technical discussions or provide any items, data, or assistance. This certification must be signed by a duly authorized officer of the company.

Point of Contact:_______________________________ Title:_______________________________________

Phone Number: _______________________________ Email Address:_______________________________

Registration Requirements:

All Fairlead suppliers who are U.S. entities or persons must comply with the U.S. regulatory requirements contained in the U.S. International Traffic in Arms Regulations (ITAR); 22 CRF §122.1:

(a) Any person who engages in the United States in the business of either manufacturing or exporting defense articles or furnishing defense services is required to register with the Directorate of Defense Trade Controls. Manufacturers who do not engage in exporting must nevertheless register.

Is your company registered with the Directorate of Defense Trade Controls, U.S. Department of State?

Yes Expiration Date (MM/DD/YYYY): ________________ *If yes a copy of the registration letter must be submitted with this vendor qualification and renewal form

In Progress Application Date(MM/DD/YYYY): ________________

No Provide explanation below

I am not required to be registered with the U.S. Department of State for the following reasons:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

ITAR Certification Statement: Please read the statement and sign below

Export Controlled Goods, Data, and Services: I understand that certain goods, data, and/or services to be provided by Fairlead under a contract or purchase order may be subject to U.S. Government export control laws and regulations including the International Traffic in Arms Regulations (ITAR) and the Export Administration Regulations (EAR). Goods or data that are subject to export controls and provided by Fairlead will normally be clearly marked as such. Controlled services will also be clearly identified. I understand that I am obligated to contact Fairlead immediately to obtain an export control determination in cases where export control jurisdiction has not been clearly marked or otherwise identified by Fairlead. I understand that providing access to U.S. export controlled goods, data, or services to non-U.S. persons either in the U.S. or abroad is prohibited without prior written authorization from the U.S. Government.

I certify that to the best of my knowledge the above information is true and correct and that our company shall be responsible for ensuring that the requirements of this certification are conveyed to all sub-tier suppliers that receive Fairlead’s technical data, or equipment or technology.

Printed Name:________________________________________ Company Name:________________________________

Signature: ___________________________________________ Date:_________________________________________

Page 8: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

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Vendor Qualification and Renewal Form

Section 8. Conflict Minerals Certification

When completing this certification, you will decide whether your product uses or incorporates any covered metals (tin, tungsten, tantalum and gold). Multiple products with different certification results must be covered by a separate certification form. Please attach any additional certifications to your Vendor Qualification and Renewal Form response.

Covered Product (s):_______________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

☐ Yes The product (s) contains covered metals, even in trace amounts ☐ The covered metals are derivatives from sources with the covered region ☐ The covered metals are derivatives from scrap or sources outside the covered region (source documentation must be maintained) ☐ The covered metals are derivatives from unknown sources. Please describe actions being taken to identify the source (below or on an attached document.)

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

☐ No Our products do not contain, in any form, any of the listed derivatives metals.

☐ No These derivatives are used for production and no amount is left on or in the final product. These derivatives are not necessary to the functionality of the product. Note: This response will require technical documentation supporting your statement, and should be available if requested at a future date.

☐ No Any other explanation supporting your assertion as explained below: ____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

☐ Unknown On a separate attachment, please describe your efforts to investigate and determine your

product(s) inclusion of any covered derivative metals, and if included in your product(s), the source of the “Conflict Minerals” contained in the derivatives.

Conflict Minerals Certification Statement: I certify that to the best of my knowledge the above information is true and correct and that our company shall be responsible for ensuring that the requirements of this certification. Certifying Official Name:______________________________________ Title:________________________________________ Office Phone:________________________________ Email:_______________________________________ Date:________________________________________

Page 9: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 9 of 13

Vendor Qualification and Renewal Form

Section 9. Suspension and Debarment

To protect the government's interests, any agency can exclude (i.e., debar or suspend) parties from receiving federal contracts or assistance for a range of offenses. Exclusions of companies or individuals from federal contracts or other funding are listed in the Excluded Parties List System (EPLS).

Please mark the statements below indicating the status of your company.

We [ ] are [ ] are not presently on the Excluded Parties List, debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

We [ ] have [ ] have not within a three-year period preceding this certification been convicted of or had a civil judgment rendered against us for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

We [ ] are [ ] are not presently indicted for or otherwise criminally charged by a governmental entity (Federal, State or Local) with commission of any of the offenses enumerated in Paragraph (b) above; and

We [ ] have [ ] have not within a three-year period of this certification had one or more public transactions (Federal, State or Local) terminated for cause or default.

I certify that to the best of my knowledge the above information is true and correct and that our company shall notify Fairlead if any change of suspension or debarment occurs.

Printed Name:________________________________________ Company Name:________________________________

Signature: ___________________________________________ Date:_________________________________________

Page 10: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 10 of 13

Vendor Qualification and Renewal Form

Section 10. DFARS 252.204-7012 Safeguarding Covered Defense Information & Cyber Incident Reporting

The above requirement, updated in October 2016, applies to all contracts released by the U.S. Department of Defense after December 2015 and is a mandatory flow down clause. Prime contractors, their subcontractors and non-commercial item suppliers must be fully compliant by 31 December 2017 in order to receive new awards, option exercises, or contract modifications on existing contracts.

Is your company compliant with the 110 controls per NIST SP 800-171?

Yes Completion Date (MM/DD/YYYY): ________________

In Progress Indicate Number of Controls Completed :

____ Implemented

____ Partially Implemented

____ Planned

____ Not Implemented

____ Not Applicable 110 Total

No We supply only commercial products or services as defined under FAR Part 2.101 (From Section 5, Scope of Qualifications)

I certify that to the best of my knowledge the above information is true and correct and that our company shall notify Fairlead if any change to NIST SP 800-171 controls occurs.

Printed Name:________________________________________ Company Name:________________________________

Signature: ___________________________________________ Date:_________________________________________

Section 11. Acknowledgements

_______Initial I have read and agree with Fairlead’s attached general terms and conditions and understand that they will apply to all orders placed unless mutually agreed changes are effective.

_______Initial I acknowledge that additional terms may be flowed down on to orders that are specific to customer contract requirements

_______Initial I acknowledge my requirement to notify Fairlead of any changes to licenses, certification, principal ownership, operating facilities, or any certifications made herein.

_______Initial I acknowledge Fairlead’s right to conduct a Quality System Audit

Section 12. Vendor Approval Signature

I certify the above information to be correct at the time of this submittal.

By: ____________________________________ Date: _________________________________

Page 11: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

Document: QSP7 Att5 Revision: 4 Effective Date: 5/05/2017 Approval: Director Purchasing Page: 11 of 13

Vendor Qualification and Renewal Form

Title: _________________________________

Remainder of Form is Fairlead Internal use only

Section 13. Vendor Approval Type

Indirect Only (Supplier will not be used to provide materials used on Customer Direct Products)

• Section 14 – 15 Not Required

Purchasing Manager Recommendation ☐ Approve ☐ Deny Scope Code: IND

Signature:______________________________ Date:____________________

Vendor Number: ______________________ Terms: ___________________________

Direct (Supplier is approved to provide materials used to manufacture Customer Direct Products)

• Sections 14 – 15 Required

Page 12: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

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Vendor Qualification and Renewal Form

Section 14. Purchasing Review of Vendor Qualifications

Yes No Vendor Qualification and Renewal Form submission is complete and acceptable

Yes No N/A Quality Certificate is attached

Yes No N/A Other stated/claimed accreditations or certifications are attached

Yes No N/A Authorized Distributer / Dealer certifications are attached

Yes No N/A SAM.Gov registration Verified (Attach results)

Yes No N/A GIDEP Registration Verified (Attach results)

Yes No N/A Negative reports on GIDEP (Attach results)

Yes No N/A ERAI Registration Verified (Attach results)

Yes No N/A No Negative Reports on ERAI (Attach results)

Yes No ITAR Certification is complete and signed

Yes No Conflict Minerals Certification(s) are completed IAW Fairlead Conflict Minerals Policy

Yes No Suspension and Debarment responses are appropriate for Vendor approval and signed

Yes No Excluded Parties List checked / vendor response verified (Attach results)

Yes No DFARS 252.204-7012 Certification is complete and signed.

Yes No All Acknowledgements are initialed

Yes No Vendor Approval signed by an appropriate representative of the vendor organization

Yes No Credit Check (Attach results) Date of Credit Check:________________

Purchasing Manager Recommendation ☐ Approve ☐ Deny Scope Code:________________

Signature:______________________________ Date:____________________

Vendor Number: _______________________ Terms: ___________________________

Reviewer’s Notes:____________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Page 13: Document: QSP7 Att5 Vendor Qualification and …fairleadint.com/.../07/FPMI-705-QSP7-Att5-Vendor-Qualification.pdfPlease return the completed Vendor Qualification and Renewal Form

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Vendor Qualification and Renewal Form

Section 15. Quality Manager Review of Vendor Qualifications

Yes No Information and recommendations from section 13 support approval

Yes No Quality certification is appropriate for intended use / scope of approval

Yes No Special process information / certifications are appropriate for intended use / scope of approval

Yes No Site Audit performed (Attach results)

Yes No Certification dates are current, valid and do not expire during annual approval.

- Document expiration dates in the notes field below.

Other – Project / Contract Specific Requirements – Define on lines below:

Yes No ______________________________________________________________________________

Yes No ______________________________________________________________________________

Yes No ______________________________________________________________________________

Quality Manager Recommendation ☐ Approve ☐ Deny

Recommended Annual Renewal Date:________________________________

Signature:______________________________ Date:____________________

Reviewer’s Notes:____________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________