Supplier Information

HEADQUARTERS INFORMATION
(If an individual complete with your personal information)
Name Carlos E Valencia
D.B.A. (if applicale)
Address !"" # $$% &
City 'ooele
&tate (tah )ip Code *+%,+
Enter a &eparate Address for -. Bo/ Information or remit to address0 if applicale
Address
City
&tate )ip Code
Corporate Contact Information
Account 1ana2er
-hone
3a/
Email
Industry Information
#esite ((45)
Duns6 (D7B)
&tandard 'erms
-ayment 'erms Discount 'erms
(Watsons standard payment terms are Net 30, unless a reasonable discount is offered)
Indicate your usual &hippin2 'erms
3rei2ht 8 Inco terms
(chec9 one)
3.B -oint (chec9 one)
a) C-' -re -aid and Allowed a) Destination
) C34 -re -ay and Add ) &hippin2 -oint
c) .ther :::::::::::::::
Page 1 of 3
Supplier Information
EFT PAYMENT INFORMATION
Watson prefers to make EFT payments. If you choose EFT as your
payment method complete the EFT information below.
ame
!ank ame
!ank "outing umber
!ank #ccount umber
#ccounting $ontact Information
$ontact
-hone
3a/
Email
The accounting email (ao!e" #ill e u$e% to tran$mit Supplier Remittance A%!ice for
tho$e recei!ing EFT pa&ment
Su$titute IRS Form '() ( Re*ue$t for Ta+pa&er Numer an% ,ertification
Name- ,arlo$ .alencia
/u$ine$$ Name- S0,1D22222222222222222222222222222222222222222222222222222
,hec3 Appropriate /o+
; < = Individual ; = Corporation ; = Partnership ; = Other ____
Ta+pa&er I%entification Numer (TIN"
Enter your 'IN in the appropriate o/. 3or Individuals0 this is your social security numer (&&N).
3or other entities0 it is your employer identification numer (EIN). >owever0 if you do not have a
numer or if you are a resident alien0 sole proprietor0 or disre2arded entity see -art I instructions
for completin2 I4& #?! at [email protected].
Social Securit& Numer 4 OR ( Emplo&er I%entification Numer
no %a$he$ plea$e
% * A * % + B $ +
Page % of 3
Certification
&nder penalties of per'ury( I certify that the number shown on this form is my correct ta)payer
identification number.
PRINT NAME: CARLOS VALENCIA_________ TITLE: Police Office___________
SIGNATURE: Carlos Valencia__________ DATE: !"#"$%_______________
&USINESS O'NERS(IP STATEMENT
In accor)ance *it+ ,o-ern.ent an) cor/orate /olic0 re12ire.ent34 'at3on P+ar.ace2tical34 Inc5 /artici/ate3 in t+e U5S5 Go-ern.ent63 S.all4 S.all
Di3a)-anta,e)4 Veteran4 Ser-ice Di3a7le) Veteran4 (U&8one an) 'o.en9o*ne) 723ine33 /ro,ra.35 T+i3 re12ire3 *ritten )oc2.entation fro. o2r S2//lier3
an) Contractor3 a3 to t+eir 723ine33 cla33ification an) c2rrent 3tat235 Plea3e c+ec: all t+e a//lica7le 7o;e3 7elo*4 3i,n an) ret2rn t+i3 for. *it+ t+e a//ro/riate
)oc2.entation5 Yo2 .23t /ro-i)e 0o2r or,ani<ation63 3tat23 an) 32//ortin, )oc2.entation for incl23ion on o2r A//ro-e) S2//lier Li3t5
Company Name:
Street Address: City: State: Zip:

Product or Service: Main NAIC Code:
(See www.census.gov/epcd/www/naics.htm !
Pre"erred Phone: #a$:
%&Mai Address: 'e(site Address:
)))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))
Please check all applicable boxes:
Lar,e &23ine33
Any (usiness that does not meet the criteria to *uai"y as a sma disadvantaged (usiness concern. YES NO
S.all &23ine33
A (usiness that is independenty owned and operated+ not dominate in its "ied o" operation, that meets the criteria and si-e standards speci"ied in the code o" "edera
reguations (./C#0 part .1.+ see #A0 .2..31!. YES NO
Minorit0 &23ine33
A (usiness (arge or sma! physicay ocated in the 4nited States or its 5rust 5erritories, at east 6.7 owned+ controed and operated (y one or more minority group
mem(ers. In the case o" any pu(ic owned (usiness+ 6.7 o" the stoc8 is owned (y one or more minority group mem(ers. Minority group mem(ers are 4.S. citi-ens
who (eong to the "oowing ethnicities: A"rican Americans+ 9ispanic Americans+ Native Americans (American Indians+ %s8imos+ Aeuts and native 9awaiians!+ Asian&
Paci"ic Americans (4.S. citi-ens whose origins are "rom :apan+ China+ the Phiippines+ ;ietnam+ <orea+ Samoa+ =uam+ the 4.S. 5rust 5erritories o" the Paci"ic+
Northern Marianas+ >aos+ Cam(odia+ 5aiwan!. Asian&Indian Americans (4.S. citi-ens whose origins are "rom India+ Pa8istan and ?angadesh!. YES NO
(If yes, please note applicable certification and include a copy of the certification).
Certification with regional Minority Supplier Diersity Council Other !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
S.all )i3a)-anta,e) 723ine33 concern
is is not certi"ied (y the Sma ?usiness Administration as a sma disadvantaged (usiness concern and identi"ied+ on the date o" this representation+ as a certi"ied sma
disadvantaged (usiness concern in the data(ase maintained (y the Sma ?usiness Administration (@ynamic Sma ?usiness Search!+ and that no materia change in
disadvantaged ownership and contro has occurred since its certi"ication+ and+ where the concern is owned (y one or more individuas caiming disadvantaged status+ the net
worth o" each individua upon whom the certi"ication is (ased does not e$ceed AB63+333 a"ter ta8ing into account the appica(e e$cusions set "orth at ./ C#0 .1C..3CD(1!,
or
does does not se"&certi"y as a sma disadvantaged (usiness concern where the concern is owned (y one or more individuas caiming disadvantaged status+ the net worth
o" each individua upon whom the certi"ication is (ased does not e$ceed AB63+333 a"ter ta8ing into account the appica(e e$cusions set "orth at ./ C#0 .1C..3CD(1!.
'o.en9O*ne) &23ine33
A (usiness that is at east 6.7 owned (y one or more women an" whose management and daiy (usiness operations are controed (y one or more women. YES
NO (If yes, include any certifications)
(278one
Sma (usinesses ocated in Ehistoricay under&utii-edF (usiness -ones (areas o" high and persistent unempoyment!. Not ony must the (usiness (e ocated in one o"
these E-onesF+ (ut aso at east /67 o" the empoyees must reside in a -one. 5o *uai"y as a 9u(Zone (usiness+ the 4.S. Sma ?usiness Administration must certi"y the
company. YES NO
Veteran9O*ne)
Sma (usinesses in which 6.7 o" the ownership is hed (y one or more ;eterans (as de"ined in /G 4.S.C. .3.(.1! or+ in the case o" any pu(icy owned (usiness+ 6.7
or more o" the stoc8 is owned (y one or more ;eterans, and the management and daiy (usiness operations are controed (y one or more ;eterans. YES NO
Ser-ice9Di3a7le) Veteran S.all &23ine33
?usinesses owned (y a ;eteran or ;eterans (see a(ove!. 5o (e "urther cassi"ied as Service&@isa(ed in accordance with /G 4.S.C. .3(.1!+ the ;eteran or ;eterans
must have a disa(iity/or disa(iities that are Service connected as de"ined in /G 4.S.C. .3.(.H!. YES NO
Le37ian Ga0 &i9Se;2al Tran3,en)er O*ne) &23ine33
A (usiness that is at east 6.7 owned (y one or more >=?5 and whose management and daiy (usiness operations are controed (y one or more >=?5. YES NO
Page % of 3
$ertification is re*uired by an authori+ed representati,e ,erifying the information submitted is true. In accordance with 1- &...$ /0-1d2( any person who misrepresents a firm3s proper si+e classification
shall 112 be punished by imposition of a fine( imprisonment( or both4 1%2 be sub'ect to administrati,e remedies4 and 132 be ineligible for participation in programs conducted under the authority of the .mall
!usiness #ct.
#uthori$e" Signature an" %itle: @ate:
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