Employee Self-Evaluation s2
Supplier Application Supplement (due diligence) /
IAP Worldwide Services, Inc., including its subsidiaries and affiliates (collectively "IAP" or the "Company") strives to conduct business domestically and abroad, consistent with the highest ethical standards and in accordance with our core values of Respect, Responsibility and Integrity. For purposes of this Supplemental questionnaire, the proposed third party provider is referred to as “Provider.” To fulfill its obligations under all applicable laws, rules, regulations as well as internal policies and procedures, IAP requires its third-party providers with whom the Company transacts business to provide certain information for IAP's review prior to entering into a definitive relationship. Accordingly, IAP requests responses to all of the questions below as fully and accurately as possible. If a question is not applicable, or if you do not know the answer, so indicate in your response. Finally, please attach all requested additional documents to this completed questionnaire.
Provider’s BUSINESS INFORMATION / TELEPHONE:
Legal Entity/Company Name:
FULL Address: / Email:
Website
Type of Business Relationship:
Sponsor/Representative International Consultant Professional/Technical Service Provider
Joint Venture Partner Other ______
10. If in question 2 on the Supplier Application you selected Individual /Sole Proprietor please complete the following:
Last Name: First Name: Middle Name: Suffix:
Date of Birth: Place of Birth SSN: Are you a U.S. Citizen (circle one) YES / NO
Home Address:
City: County: State Zip:
Driver’s License Number:
Contact Telephone Numbers Home: Work: Cell:
11. To the best of your knowledge, has the Individual Provider or any owner, principal, senior manager or authorized agent of the Legal Entity Provider ever been named on any sanctions list maintained by the U.S. Government, the United Nations or any other governmental entity or public international organization OR been named on one of the following
a) Specially Designated National list (http://www.treas.gov/offices/enforcement/ofac/sdn/),
b) Denied Persons list (http://www.bis.doc.gov/dpl/thedeniallist.asp),
c) Unverified list (http://www.bis.doc.gov/Enforcement/UnverifiedList/unverified_parties.html), or the
d) Debarred list (http://www.pmddtc.state.gov/debar059.htm) issued by the U.S. Departments of State, Commerce and Treasury; or
Yes No
If yes, provide details:
12. To the best of your knowledge, has the Individual Provider or any owner, principal, senior manager or authorized agent of the Legal Entity Provider ever engaged in a transaction that involves:
a) the receipt, transfer, transportation, retention, use, structuring, diverting, or hiding the proceeds of any criminal activity whatsoever, including drug trafficking, fraud and bribery of a public official;
b) engaging or becoming involved in, financing, or supporting or giving aid or comfort to any terrorist person, activity or organization; or a
c) Designated Person? [i]
Yes No
If yes, provide details:
13. Will subcontractors be used to perform any work under the proposed engagement Yes No
If yes, please identify and provide full contact information for any subcontractors:
14. Has there been any change in ownership in the last 2 years? Yes No
15. Date business was established:
16. Number of Employees:
17. Taxpayer Identification Number
18. Is the Provider, any owner, employee, or officer, or any family member of the Provider or of an owner, employee or officer of the Provider, an employee of any U.S. government department, agency or instrumentality (whether executive, legislative, judicial or administrative, and including the military), and including government-owned or controlled entities?
Yes No
If yes, list names, titles, government positions, and dates of service as U.S. government employee.
19. Has the Provider, any associated organization, any present or former principal officer, director, employee, or shareholder ever been suspended or debarred from doing business in any capacity, been charged with any criminal act, or been the subject of any allegations of fraud, misrepresentation, bribery, or other criminal or otherwise illegal activities in the U.S. or any other country?
Yes No
If yes, please provide complete details. (Use a separate attachment, if necessary.)
20. Does the Provider or any owner, employee or officer of the Provider have any familial relationship, business relationship, or other relationship posing a potential conflict of interest with any individual within IAP’s organization?
Yes No
If yes, please provide complete details.
21. List previous or current agreements, if any, with IAP or any of its affiliates.
22. For Legal Entities only: is the entity registered in the country where the services are to be performed?
Yes No
If no, why not?
23. Is the Provider prepared to represent in writing that the amounts paid are received for his own account, and that no amounts will be passed on to Government officials or persons in a conflict of interest position?
Yes No
If no, why not?
24. If the Provider wants to be paid by wire transfer, is the Provider’s payee bank in its name and country of residence? If it is not in the country of Provider’s residence, where does the Provider request payment to be sent, and why?
Yes No
25. List the market sectors (municipalities, national government, contractors, or industry) in which the Provider actively solicits business and the estimated volume of sales for the Contracting Party.
26. If Provider is an individual, please provide resume. OR
If Provider is a Legal Entity, please provide copies of: company brochures, annual reports, and any other documentation deemed appropriate. Also, please attach the Provider’s latest fiscal balance sheet and operating statement hereto.
27. List five (5) neutral business references and highlights of their relationship to Provider. Business references who have utilized Provider for similar services are preferred. Alternatively, list references familiar with Provider and its services.
Please do not include IAP personnel or Provider’s affiliated companies.
Company Name
& Point of Contact / Email / Phone / Period of Performance / Nature of relationship/activities
Supplier Application Supplement Certification
I certify that the information provided in each of the items is true and correct to the best of my knowledge. I understand that IAP Worldwide Services, Inc., will rely on the above information in determining whether to enter into any contractual agreement with ______and that any false or misleading information provided by ______would be grounds for the immediate termination of any such contractual agreement.
Print name:Signature:
Title:
Date:
Form #5000-015 / Page 3 of 3 / Effective Date: 31-Dec-2015
This material contains proprietary information of IAP Worldwide Services, Inc. (IAP). Disclosure to others, use, or copying without the express written authorization of IAP is strictly prohibited. Any authorized copying of this material, in whole or in part, must include this legend.
[i] Designated Person means any person, entity or country (1) whose name is specified in, or pursuant to, any Executive Order issued by the President of the United States of America relating to the designation of a person as a terrorist or terrorist organization or blocking any assets of such person; (2) in respect of whom any person has received notice from the United States Government that all financial transactions involving the assets of such person have been, or are to be, blocked; (3) who is designated from time to time by either Executive Order of the President of the United States, or in published lists issued by the United States Treasury Department (and its Office of Foreign Assets Control) including the Specially Designated Nationals (“SDN”) list, the United States Department of Commerce or the United States Department of State, as a foreign terrorist organization or an organization that assists or provides support to a foreign terrorist organization or a party subject to sanctions; or (4) who is or was convicted, found guilty or against whom a judgment or order was entered in any proceedings for violating money laundering, anti-corruption or bribery, or international economic or anti-terrorism sanction laws, or whose assets were seized, blocked, frozen or ordered forfeited for violation of money laundering or international anti-terrorism laws.