Form C.33 - Pk/pl - New Jersey Public Law Form

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KEAN UNIVERSITY
NEW JERSEY PUBLIC LAW 1977 C. 33
RFQ# ________________
THIS ENCLOSURE MUST BE COMPLETED, SIGNED, AND RETURNED WITH THE BID OR YOUR BID WILL BE INVALID
Pursuant to N.J.P.L. 1977. Chapter 33. the supplier must provide a complete list of names and address of all persons who fall into any of the following
categories
(If additional space is required, use separate sheet and attach)
1. If a is a Corporation, Supplier hereby certifies that the following is a complete list of the names of stockholders who own 10% or more of its stock of
any class:
NAMES
ADDRESSES
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
NAME OF CORPORAT ION _________________________________________
BY ______________________________________
________________________________DATE_______________________
(AUTHORIZED REPRESENTATIVE (PRINT)
SIGNATURE
2. If the Supplier is a Partnership, Supplier hereby certifies that the following is a list of all partners who own 10% or greater interest in the assets, profit,
or cash flow of Supplier.
NAMES
ADDRESSES
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
NAME OF PARTNERSHIP ___________________________________________
BY _____________________________________
________________________________DATE_______________________
(AUTHORIZED REPRESENTATIVE (PRINT)
SIGNATURE
3. If Supplier is either a Partnership or a Corporation , and one or more stockholder or partner is itself a Corporation or Partnership, the Supplier must list
the stockholders holding 10% or more of that corporation or the individual partners owning a 10% or greater interest in that partnership, as the case may
be.
(STOCK/INTEREST IN)
NAMES
ADDRESSES
NAMES OF CORPORATION/PARTNERSHIP
___________________________
_____________________________
_____________________________________
___________________________
_____________________________
_____________________________________
___________________________
_____________________________
_____________________________________
SUBMITTED BY: _______________________________________________________
NAME OF FIRM
BY ______________________________________
_______________________________DATE________________________
(AUTHORIZED REPRESENTATIVE (PRINT)
SIGNATURE
4. If Supplier has previously provided the University with the information required by N.J.P.L. 1977 C 33 on this form, and there has been no change of
ownership of Supplier since such information was provided, or the Supplier is a sole proprietorship, the foregoing is not required, but THE SUPPLIER
MUST SING BELOW FOR CERTIFICATIONS.
Purchase order or RFQ number ____________________________Date: ________________________ (If applicable)
NAME OF FIRM _______________________________________________________________
BY _____________________________________
______________________________DATE_________________________
(AUTHORIZED REPRESENTATIVE (PRINT)
SIGNATURE
Above information must be returned to:
Kean University
University Purchasing
1000 Morris Avenue
Union, NJ 07083
PK/PL 1977/06

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