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URL: https://ppm.bnl.gov/MosrcOutEmail/NewMosrc/c3dae99a-6f50-4152-b81f-c79cc69a3d36
Submission: On November 15 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST /MosrcOutEmail/NewMosrc/c3dae99a-6f50-4152-b81f-c79cc69a3d36

<form action="/MosrcOutEmail/NewMosrc/c3dae99a-6f50-4152-b81f-c79cc69a3d36" method="post" novalidate="novalidate"><input name="__RequestVerificationToken" type="hidden"
    value="10sATzFdkuwgDc_4dB8lv3mtxal_UqEKrhUlQGcJ7oqwoP8ptfpT5RuldT2ULwBOnV2qZ0ZouJPz3tyWoKHBtYjHbPqOfyczbcunRa0NaJ41"><input date="11/15/2024 00:00:00" day="15" dayofweek="Friday" dayofyear="320" hour="0" kind="Unspecified" millisecond="0"
    minute="0" month="11" second="0" ticks="638672256000000000" timeofday="00:00:00" year="2024" data-val="true" data-val-date="The field PO_Date must be a date." id="mosrcOutEmailVM_PO_Date" name="mosrcOutEmailVM.PO_Date" type="hidden"
    value="11/15/2024 12:00:00 AM"><input date="11/15/2024 00:00:00" day="15" dayofweek="Friday" dayofyear="320" hour="0" kind="Unspecified" millisecond="0" minute="0" month="11" second="0" ticks="638672256000000000" timeofday="00:00:00" year="2024"
    data-val="true" data-val-date="The field OfficialMosrcDate must be a date." data-val-required="The OfficialMosrcDate field is required." id="OfficialMosrcDate" name="OfficialMosrcDate" type="hidden" value="11/15/2024 12:00:00 AM">
  <div class="editor-container">
    <h3>MOSRC Information Request</h3>
    <hr>
    <div class="editor-label-wide">
      <label for="PO_Number:">PO Number:</label>
    </div>
    <div class="editor-field"> 0000456538 <span class="field-validation-valid" data-valmsg-for="mosrcOutEmailVM.Award_Number" data-valmsg-replace="true"></span>
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="PO_Change_Order_Number:">PO Change Order Number:</label>
    </div>
    <div class="editor-field"> 0 <span class="field-validation-valid" data-valmsg-for="mosrcOutEmailVM.CO_Award_Number" data-valmsg-replace="true"></span>
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Vendor_DUNS_Number:">Vendor DUNS Number:</label>
    </div>
    <div class="editor-field">
      <input class="text-box single-line" data-val="true" data-val-length=" * cannot exceed 9 numbers" data-val-length-max="9"
        data-val-regex=" * must be numeric and exactly nine numbers (add leading 0s if needed) and please be sure there is no spaces after the ninth digit" data-val-regex-pattern="^[0-9]{9}$" id="Sub_DUNS" name="Sub_DUNS" type="text" value="">
      <span class="field-validation-valid" data-valmsg-for="Sub_DUNS" data-valmsg-replace="true"></span>
      <label id="lblDunsAsterisk" style="display: none;">*</label>
    </div>
    <br class="clear">
    <br>
    <div id="divDunsLookup" style="display: none;">
      <p></p>
      <h6>To look up your DUNS number, please search the SAM database using link below: </h6>
      <a target="_blank" href="https://sam.gov/search">DUNS Lookup</a>
      <p></p>
    </div>
    <div class="editor-label-wide">
      <label for="Vendor_UEI_Identifier:">Vendor UEI Identifier:</label>
    </div>
    <div class="editor-field">
      <input class="text-box single-line" data-val="true" data-val-length=" * UEI must be 12 characters long!" data-val-length-max="12" data-val-length-min="12" data-val-regex=" * Can only contain letters and numbers.  Please correct."
        data-val-regex-pattern="^[a-zA-Z0-9]+$" id="Sub_UEI" name="Sub_UEI" type="text" value="">
      <span class="field-validation-valid" data-valmsg-for="Sub_UEI" data-valmsg-replace="true"></span>
      <label id="lblUeiAsterisk">*</label>
    </div>
    <br class="clear">
    <br>
    <div id="divUEILookup">
      <h6>To look up your UEI number, please search the SAM database using link below: </h6>
      <a target="_blank" href="https://sam.gov/search">UEI Lookup</a>
      <br class="clear">
      <br>
    </div>
    <div class="editor-label-wide">
      <label for="Vendor_Name:">Vendor Name:</label>
    </div>
    <div class="editor-field">
      <input class="text-box single-line" data-val="true" data-val-length=" * cannot exceed 50 characters" data-val-length-max="50" data-val-required=" * please enter a value." id="Vendor_Name" name="Vendor_Name" type="text" value="">
      <span class="field-validation-valid" data-valmsg-for="Vendor_Name" data-valmsg-replace="true"></span> *
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Anticipated_PO_Date:">Anticipated PO Date:</label>
    </div>
    <div class="editor-field"> 11/15/2024 <span class="field-validation-valid" data-valmsg-for="mosrcOutEmailVM.PO_Date" data-valmsg-replace="true"></span>
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="PO_Value:">PO Value:</label>
    </div>
    <div class="editor-field"> $ 1353.92 <span class="field-validation-valid" data-valmsg-for="mosrcOutEmailVM.PO_CO_Value" data-valmsg-replace="true"></span>
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Size_Deterimination_from_NAICS_Code_for_Order:">Size Deterimination from NAICS Code for Order:</label>
    </div>
    <div class="editor-field"> 1000 <span class="field-validation-valid" data-valmsg-for="mosrcOutEmailVM.Size_Standard" data-valmsg-replace="true"></span>
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="NAICS_Code_for_Order:">NAICS Code for Order:</label>
    </div>
    <div class="editor-field"> 334516 <span class="field-validation-valid" data-valmsg-for="mosrcOutEmailVM.NAICS_Code" data-valmsg-replace="true"></span>
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Solicitation_Description:">Solicitation Description:</label>
    </div>
    <div class="editor-field"> rotation stage </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Place_of_Performance_City:">Place of Performance City:</label>
    </div>
    <div class="editor-field">
      <input class="text-box single-line" data-val="true" data-val-regex=" * must be letters" data-val-regex-pattern="^[A-Za-z\s]+$" data-val-required=" * please enter a value." id="Sub_POP_City" name="Sub_POP_City" type="text" value="">
      <span class="field-validation-valid" data-valmsg-for="Sub_POP_City" data-valmsg-replace="true"></span> *
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Place_of_Performance_State:">Place of Performance State:</label>
    </div>
    <div class="editor-field">
      <select data-val="true" data-val-length=" * cannot exceed 2 characters" data-val-length-max="2" data-val-regex=" * must be letters and exactly two characters" data-val-regex-pattern="^[A-Za-z]{2}$" data-val-required=" * please enter a value."
        id="Sub_POP_State_Code" name="Sub_POP_State_Code">
        <option value=" ">Choose Your State</option>
        <option value="AL">Alabama</option>
        <option value="AK">Alaska</option>
        <option value="AZ">Arizona</option>
        <option value="AR">Arkansas</option>
        <option value="CA">California</option>
        <option value="CO">Colorado</option>
        <option value="CT">Connecticut</option>
        <option value="DE">Delaware</option>
        <option value="DC">District of Columbia</option>
        <option value="FM">Federated States of Micronesia</option>
        <option value="FL">Florida</option>
        <option value="GA">Georgia</option>
        <option value="GU">Guam</option>
        <option value="HI">Hawaii</option>
        <option value="ID">Idaho</option>
        <option value="IL">Illinois</option>
        <option value="IN">Indiana</option>
        <option value="IA">Iowa</option>
        <option value="KS">Kansas</option>
        <option value="KY">Kentucky</option>
        <option value="LA">Louisiana</option>
        <option value="ME">Maine</option>
        <option value="MH">Marshall Islands</option>
        <option value="MD">Maryland</option>
        <option value="MA">Massachusetts</option>
        <option value="MI">Michigan</option>
        <option value="MN">Minnesota</option>
        <option value="MS">Mississippi</option>
        <option value="MO">Missouri</option>
        <option value="MT">Montana</option>
        <option value="NE">Nebraska</option>
        <option value="NV">Nevada</option>
        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
        <option value="NY">New York</option>
        <option value="NC">North Carolina</option>
        <option value="ND">North Dakota</option>
        <option value="MP">Northern Mariana Islands</option>
        <option value="OH">Ohio</option>
        <option value="OK">Oklahoma</option>
        <option value="OR">Oregon</option>
        <option value="PW">Palau</option>
        <option value="PA">Pennsylvania</option>
        <option value="PR">Puerto Rico</option>
        <option value="RI">Rhode Island</option>
        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
        <option value="TX">Texas</option>
        <option value="UT">Utah</option>
        <option value="VT">Vermont</option>
        <option value="VI">Virgin Islands</option>
        <option value="VA">Virginia</option>
        <option value="WA">Washington</option>
        <option value="WV">West Virginia</option>
        <option value="WI">Wisconsin</option>
        <option value="WY">Wyoming</option>
      </select>
      <span class="field-validation-valid" data-valmsg-for="Sub_POP_State_Code" data-valmsg-replace="true"></span> *
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Place_of_Performance_Zip_Code:">Place of Performance Zip Code:</label>
    </div>
    <div class="editor-field">
      <input class="text-box single-line" data-val="true" data-val-length=" * cannot exceed 10 characters" data-val-length-max="50" data-val-regex=" * invalid Zip Code (XXXXX-XXXX)" data-val-regex-pattern="^\d{5}-\d{4}$"
        data-val-required=" * please enter a value." id="Sub_POP_Zip_Code" name="Sub_POP_Zip_Code" type="text" value="">
      <span class="field-validation-valid" data-valmsg-for="Sub_POP_Zip_Code" data-valmsg-replace="true"></span> *
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <b><label for="Place_of_Performance_County_Name:" style="color:red">Place of Performance County Name:</label></b>
    </div>
    <div class="editor-field">
      <input class="text-box single-line" data-val="true" data-val-length=" * cannot exceed 35 characters" data-val-length-max="35" data-val-regex=" * must be letters" data-val-regex-pattern="^[A-Za-z\s]+$"
        data-val-required=" * please enter a value." id="Sub_POP_Country_Name" name="Sub_POP_Country_Name" type="text" value="">
      <span class="field-validation-valid" data-valmsg-for="Sub_POP_Country_Name" data-valmsg-replace="true"></span> * Make sure you put the <b style="color: red">COUNTY</b> here.
    </div>
    <br class="clear">
    <br>
    <div class="editor-label-wide">
      <label for="Place_of_Performance_Congressional_District:">Place of Performance Congressional District:</label>
    </div>
    <div class="editor-field">
      <input class="text-box single-line" data-val="true" data-val-length=" * cannot exceed 6 characters" data-val-length-max="3" data-val-regex=" * must be numeric and exactly three numbers - pad with zeros if necessary"
        data-val-regex-pattern="^[0-9]{3}$" data-val-required=" * please enter a value." id="Sub_POP_Congressional_District" name="Sub_POP_Congressional_District" type="text" value="">
      <span class="field-validation-valid" data-valmsg-for="Sub_POP_Congressional_District" data-valmsg-replace="true"></span> *
    </div>
    <br class="clear">
    <br>
    <p></p>
    <h6>To look up your Congressional District Number, please use your full zip code. The link is below. </h6>
    <a target="_blank" href="http://www.house.gov/representatives/find/">http://www.house.gov/representatives/find/</a>
    <p></p>
    <div class="editor-label-wide">
      <label for="Place_of_Performance_Country:">Place of Performance Country:</label>
    </div>
    <div class="editor-field">
      <select data-val="true" data-val-length=" * cannot exceed 3 characters" data-val-length-max="3" data-val-required=" * please enter a value." id="Sub_Place_of_Performance_Country_Code" name="Sub_Place_of_Performance_Country_Code">
        <option value=" ">Chooose Your Country</option>
        <option value="USA">United States</option>
        <option value="AFG">Afghanistan</option>
        <option value="ALB">Albania</option>
        <option value="DZA">Algeria</option>
        <option value="ARG">Argentina</option>
        <option value="ARM">Armenia</option>
        <option value="AUS">Australia</option>
        <option value="AUT">Austria</option>
        <option value="AZE">Azerbaijan</option>
        <option value="BHR">Bahrain</option>
        <option value="BGD">Bangladesh</option>
        <option value="BLR">Belarus</option>
        <option value="BEL">Belgium</option>
        <option value="BLZ">Belize</option>
        <option value="BTN">Bhutan</option>
        <option value="VEN">Bolivarian Republic of Venezuela</option>
        <option value="BOL">Bolivia</option>
        <option value="BIH">Bosnia and Herzegovina</option>
        <option value="BWA">Botswana</option>
        <option value="BRA">Brazil</option>
        <option value="BRN">Brunei Darussalam</option>
        <option value="BGR">Bulgaria</option>
        <option value="KHM">Cambodia</option>
        <option value="CMR">Cameroon</option>
        <option value="CAN">Canada</option>
        <option value="029">Caribbean</option>
        <option value="CHL">Chile</option>
        <option value="COL">Colombia</option>
        <option value="COD">Congo (DRC)</option>
        <option value="CRI">Costa Rica</option>
        <option value="CIV">Côte d’Ivoire</option>
        <option value="HRV">Croatia</option>
        <option value="CUB">Cuba</option>
        <option value="CZE">Czech Republic</option>
        <option value="DNK">Denmark</option>
        <option value="DJI">Djibouti</option>
        <option value="DOM">Dominican Republic</option>
        <option value="ECU">Ecuador</option>
        <option value="EGY">Egypt</option>
        <option value="SLV">El Salvador</option>
        <option value="ERI">Eritrea</option>
        <option value="EST">Estonia</option>
        <option value="ETH">Ethiopia</option>
        <option value="FRO">Faroe Islands</option>
        <option value="FIN">Finland</option>
        <option value="FRA">France</option>
        <option value="GEO">Georgia</option>
        <option value="DEU">Germany</option>
        <option value="GRC">Greece</option>
        <option value="GRL">Greenland</option>
        <option value="GTM">Guatemala</option>
        <option value="HTI">Haiti</option>
        <option value="HND">Honduras</option>
        <option value="HKG">Hong Kong S.A.R.</option>
        <option value="HUN">Hungary</option>
        <option value="ISL">Iceland</option>
        <option value="IND">India</option>
        <option value="IDN">Indonesia</option>
        <option value="IRN">Iran</option>
        <option value="IRQ">Iraq</option>
        <option value="IRL">Ireland</option>
        <option value="PAK">Islamic Republic of Pakistan</option>
        <option value="ISR">Israel</option>
        <option value="ITA">Italy</option>
        <option value="JAM">Jamaica</option>
        <option value="JPN">Japan</option>
        <option value="JOR">Jordan</option>
        <option value="KAZ">Kazakhstan</option>
        <option value="KEN">Kenya</option>
        <option value="KOR">Korea</option>
        <option value="KWT">Kuwait</option>
        <option value="KGZ">Kyrgyzstan</option>
        <option value="LAO">Lao P.D.R.</option>
        <option value="419">Latin America</option>
        <option value="LVA">Latvia</option>
        <option value="LBN">Lebanon</option>
        <option value="LBY">Libya</option>
        <option value="LIE">Liechtenstein</option>
        <option value="LTU">Lithuania</option>
        <option value="LUX">Luxembourg</option>
        <option value="MAC">Macao S.A.R.</option>
        <option value="MYS">Malaysia</option>
        <option value="MDV">Maldives</option>
        <option value="MLI">Mali</option>
        <option value="MLT">Malta</option>
        <option value="MEX">Mexico</option>
        <option value="MDA">Moldova</option>
        <option value="MNG">Mongolia</option>
        <option value="MNE">Montenegro</option>
        <option value="MAR">Morocco</option>
        <option value="MMR">Myanmar</option>
        <option value="NPL">Nepal</option>
        <option value="NLD">Netherlands</option>
        <option value="NZL">New Zealand</option>
        <option value="NIC">Nicaragua</option>
        <option value="NGA">Nigeria</option>
        <option value="MKD">North Macedonia</option>
        <option value="NOR">Norway</option>
        <option value="OMN">Oman</option>
        <option value="PAN">Panama</option>
        <option value="PRY">Paraguay</option>
        <option value="CHN">People's Republic of China</option>
        <option value="PER">Peru</option>
        <option value="PHL">Philippines</option>
        <option value="POL">Poland</option>
        <option value="PRT">Portugal</option>
        <option value="MCO">Principality of Monaco</option>
        <option value="QAT">Qatar</option>
        <option value="REU">Réunion</option>
        <option value="ROU">Romania</option>
        <option value="RUS">Russia</option>
        <option value="RWA">Rwanda</option>
        <option value="SAU">Saudi Arabia</option>
        <option value="SEN">Senegal</option>
        <option value="SRB">Serbia</option>
        <option value="SGP">Singapore</option>
        <option value="SVK">Slovakia</option>
        <option value="SVN">Slovenia</option>
        <option value="SOM">Somalia</option>
        <option value="ZAF">South Africa</option>
        <option value="ESP">Spain</option>
        <option value="LKA">Sri Lanka</option>
        <option value="SWE">Sweden</option>
        <option value="CHE">Switzerland</option>
        <option value="SYR">Syria</option>
        <option value="TWN">Taiwan</option>
        <option value="TJK">Tajikistan</option>
        <option value="THA">Thailand</option>
        <option value="TTO">Trinidad and Tobago</option>
        <option value="TUN">Tunisia</option>
        <option value="TUR">Turkey</option>
        <option value="TKM">Turkmenistan</option>
        <option value="ARE">U.A.E.</option>
        <option value="UKR">Ukraine</option>
        <option value="GBR">United Kingdom</option>
        <option value="USA">United States</option>
        <option value="URY">Uruguay</option>
        <option value="UZB">Uzbekistan</option>
        <option value="VNM">Vietnam</option>
        <option value="001">World</option>
        <option value="YEM">Yemen</option>
        <option value="ZWE">Zimbabwe</option>
      </select>
      <span class="field-validation-valid" data-valmsg-for="Sub_Place_of_Performance_Country_Code" data-valmsg-replace="true"></span> *
    </div>
    <br class="clear">
    <br>
    <h6 style="display: inline">By submitting this certification I </h6>
    <h6 style="display: inline"> am attesting to the accuracy of the representations and certifications contained herein. I understand that I may be subject to penalties if I misrepresent </h6>
    <div style="display: inline" id="BusinessNameBlank"></div>
    <h6 style="display: inline">in any of the representations or certifications to Brookhaven Science Associates and the Government.</h6>
  </div>
  <p>
    <input type="submit" value="Submit" class="btn btn-default">
  </p>
</form>

Text Content

Brookhaven National Laboratory

PPM




BROOKHAVEN NATIONAL LABORATORY MOSRC QUESTIONNAIRE


MOSRC INFORMATION REQUEST

--------------------------------------------------------------------------------

PO Number:
0000456538


PO Change Order Number:
0


Vendor DUNS Number:
*



TO LOOK UP YOUR DUNS NUMBER, PLEASE SEARCH THE SAM DATABASE USING LINK BELOW:

DUNS Lookup



Vendor UEI Identifier:
*



TO LOOK UP YOUR UEI NUMBER, PLEASE SEARCH THE SAM DATABASE USING LINK BELOW:

UEI Lookup


Vendor Name:
*


Anticipated PO Date:
11/15/2024


PO Value:
$ 1353.92


Size Deterimination from NAICS Code for Order:
1000


NAICS Code for Order:
334516


Solicitation Description:
rotation stage


Place of Performance City:
*


Place of Performance State:
Choose Your State Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware District of Columbia Federated States of Micronesia Florida
Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine
Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri
Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North
Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau
Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee
Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin
Wyoming *


Place of Performance Zip Code:
*


Place of Performance County Name:
* Make sure you put the COUNTY here.


Place of Performance Congressional District:
*





TO LOOK UP YOUR CONGRESSIONAL DISTRICT NUMBER, PLEASE USE YOUR FULL ZIP CODE.
THE LINK IS BELOW.

http://www.house.gov/representatives/find/



Place of Performance Country:
Chooose Your Country United States Afghanistan Albania Algeria Argentina Armenia
Australia Austria Azerbaijan Bahrain Bangladesh Belarus Belgium Belize Bhutan
Bolivarian Republic of Venezuela Bolivia Bosnia and Herzegovina Botswana Brazil
Brunei Darussalam Bulgaria Cambodia Cameroon Canada Caribbean Chile Colombia
Congo (DRC) Costa Rica Côte d’Ivoire Croatia Cuba Czech Republic Denmark
Djibouti Dominican Republic Ecuador Egypt El Salvador Eritrea Estonia Ethiopia
Faroe Islands Finland France Georgia Germany Greece Greenland Guatemala Haiti
Honduras Hong Kong S.A.R. Hungary Iceland India Indonesia Iran Iraq Ireland
Islamic Republic of Pakistan Israel Italy Jamaica Japan Jordan Kazakhstan Kenya
Korea Kuwait Kyrgyzstan Lao P.D.R. Latin America Latvia Lebanon Libya
Liechtenstein Lithuania Luxembourg Macao S.A.R. Malaysia Maldives Mali Malta
Mexico Moldova Mongolia Montenegro Morocco Myanmar Nepal Netherlands New Zealand
Nicaragua Nigeria North Macedonia Norway Oman Panama Paraguay People's Republic
of China Peru Philippines Poland Portugal Principality of Monaco Qatar Réunion
Romania Russia Rwanda Saudi Arabia Senegal Serbia Singapore Slovakia Slovenia
Somalia South Africa Spain Sri Lanka Sweden Switzerland Syria Taiwan Tajikistan
Thailand Trinidad and Tobago Tunisia Turkey Turkmenistan U.A.E. Ukraine United
Kingdom United States Uruguay Uzbekistan Vietnam World Yemen Zimbabwe *



BY SUBMITTING THIS CERTIFICATION I

AM ATTESTING TO THE ACCURACY OF THE REPRESENTATIONS AND CERTIFICATIONS CONTAINED
HEREIN. I UNDERSTAND THAT I MAY BE SUBJECT TO PENALTIES IF I MISREPRESENT



IN ANY OF THE REPRESENTATIONS OR CERTIFICATIONS TO BROOKHAVEN SCIENCE ASSOCIATES
AND THE GOVERNMENT.





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