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SUPPLIER CERTIFICATION

The procurement of material supplies or services for a U.S. Government contract requires compliance by prime contractors, subcontractors, and suppliers with various programs enacted into law, implemented by Executive Order and declared by Federal Regulations. Certifications on the specific requirements and your present state of compliance are contained in section 1 through 9. Section 10 is required by Ultralife to update supplier records. Section 11 is required to certify Export Compliance. Please review and complete all sections. THERE ARE NO EXCEPTIONS FOR ANY SECTIONS.

The following certifications are effective for the period of three years from the date of submission and received signature. If there is any change to your status under any of the following certifications during that period, you are required to inform Ultralife in writing promptly, within fifteen (15) days of the change in status.

PLEASE NOTE: Fields followed by a red * are REQUIRED. You will not be able to submit a page until completing all of the REQUIRED fields.

This is a five (5) page form.

Please print, SIGN, and fax or mail the completed form to one of the following:

Attn: Manager of Small Business Subcontract Programs
FAX: (315) 210-6101
MAIL: Ultralife Corporation
2000 Technology Parkway
Newark, NY 14513

Detailed instructions will be supplied upon completion of this form.

Ultralife Corporation, as a U.S. Government Contractor, is required to comply with certain laws and Federal Acquisition Regulations (FAR) that require the collection and update of certifications from each of our suppliers and subcontractors. Ultralife's family of brands and companies includes: ABLE, AMTI, McDowell Research, RedBlack Communications, RPS Power System, Stationary Power Services and Ultralife Batteries.

Supplier Classifications (Please select the appropriate category)

Potential Supplier (Currently not a supplier for Ultralife Corporation)

Current Supplier (Currently a supplier for Ultralife Corporation)

SUPPLIER INFORMATION

Company *

Location *

Address
City	State/Province	Zip / Postal Code
Country

Phone Number *

Fax Number

Supplier's DUNS Number¹: *

Number of Employees: *

CAGE/FSCM Number²: *

Billing Address:

If your billing address is the same as above, check here.

Billing Name *
Address
City	State/Province	Zip / Postal Code
Country

Name and Address of Parent Company:

Parent Name:
Parent's DUNS Number¹:
Address
City	State/Province	Zip / Postal Code
Country



Complete page one (1) of five (5)

¹ DUNS Identification Number: This is a Dun and Bradstreet (DUN) unique nine-digit identification number used by federal and commercial entities describing value-added data associated with business entities.

² CAGE Number: This is a Commercial and Government Entity (CAGE) Code, which is assigned by the Department of Defense. It is a 5-character alphanumeric value with no spaces. The CAGE number might also be refered to as a Federal Supply Code for Manufacturers (FSCM) or Business Identification Number Cross-reference System (BINCS) Number.

For additional assistance, please contact please contact
the Manager of Small Business Subcontract Programs at (315) 359-6292.

Ultralife Batteries brand - We. Are. Power.