Atmos Energy

Atmos Energy Supplier

In an effort to become more familiar with our existing supplier base, Atmos Energy requests that this form be completed at your earliest convenience. Your company's questionnaire will remain confidential and be kept on file to better manage our relationship with your company. An electronic signature can be added in this web form by an authorized representative of the company.
The form can be submitted via the "Submit" button below once completed.

* = Required

Please fill out the required field(s)

Company Name*:
Payment Address 1*:
Payment Address 2:
City*:
State*:
Zip*:
County:
Owner Name*:
Owner Title:
Company Primary Contact Name*:	First Name Last Name
Company Primary Contact Title:
Email Address*:
Phone*:	-
Fax:	-

Federal Tax ID*:

DUNS #:

Please briefly describe your products or services*:


Business Primary NAICS¹ code:
Please list applicable NAICS¹ code related to products/services provided to Atmos*:
¹NAICS codes are needed for the Summary Subcontract Report breakout report (by 3-digit NAICS subsector) that the Prime Contractor is required to submit to the Government annually pursuant to the Federal Acquisition Regulation("FAR") clause at 52.219-9(1)(2)(iii). NAICS codes for business may be found at www.sba.gov/size.

Please indicate the description that is applicable to your company (note: Please see SBA size requirements for small businesses at http://www.sba.gov. *
Large Business Small Business Charity or Non-Profit Government Entity Civic or Trade Association
If you are a large Business, do you operate a Supplier Diversity or Small Business Program? Yes No
Please indicate if your company is at least 51% owned and operated by an individual in one or more of the following categories:
Woman Owned Veteran Owned Service Disabled Veteran Owned Small Disadvantaged Business HUBZone (Federal designee only)
Please choose one group if Small Disadvantage Business is checked: *

The undersigned acknowledges under penalty per 15 U.S.C. 645(d), that the information provided herein is current and accurate. Any person who misrepresented its size status shall (1) be punished by a fine, or both; (2) be subject to administrative remedies; and (3) be inelegible for participation in programs conducted under the authority of the Small Business Act.

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Your Title*
Date*

Authorized Signature*

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*I accept the terms and conditions and authorize the signature

Small Business Size Classifications: For size clarification you may wish to review the definitions for the above categories in the Federal Acquisitions Regulation ("FAR") 19.7 or 52.219-8. If you have difficulty ascertaining your size status, please refer to the SBA's website at www.sba.gov/size or contact your local SBA office.