Supplier Information

HEADQUARTERS INFORMATION(If an individual complete with your personal information)

Name Carlos E ValenciaD.B.A. (if

applicable)Address 955 W 660 S

City TooeleState Utah Zip Code 84074

Enter a Separate Address for PO Box Information or remit to address, if applicableAddress

CityState Zip Code

Corporate Contact InformationAccount Manager

PhoneFax

EmailIndustry Information

Website (URL)Duns# (D&B)

Standard TermsPayment Terms Discount Terms

(Watson’s standard payment terms are Net 30, unless a reasonable discount is offered)

Indicate your usual Shipping TermsFreight / Inco terms(check one)

FOB Point (check one)

a) CPT Pre Paid and Allowed a) Destinationb) CFR Pre Pay and Add b) Shipping Pointc) Other _______________

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Supplier Information

EFT PAYMENT INFORMATIONWatson prefers to make EFT payments. If you choose EFT as your payment method complete the EFT information below.

NameBank Name

Bank Routing Number

Bank Account Number

Accounting Contact InformationContactPhone

FaxEmail

The accounting email (above) will be used to transmit Supplier Remittance Advice for those receiving EFT payment

Substitute IRS Form W-9 - Request for Taxpayer Number and Certification

Name: Carlos Valencia Business Name: SLCPD_____________________________________________________Check Appropriate Box

[ X ] Individual [ ] Corporation [ ] Partnership [ ] Other ____

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Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. For Individuals, this is your social security number (SSN). For other entities, it is your employer identification number (EIN). However, if you do not have a number or if you are a resident alien, sole proprietor, or disregarded entity see Part I instructions for completing IRS W-9 at http://www.irs.gov.

Social Security Number – OR - Employer Identification Numberno dashes please

0 8 1 8 0 4 2 6 4

BUSINESS OWNERSHIP STATEMENTIn accordance with government and corporate policy requirements, Watson Pharmaceuticals, Inc. participates in the U.S. Government’s Small, Small Disadvantaged, Veteran, Service Disabled Veteran, HUBZone and Women-owned business programs. This requires written documentation from our Suppliers and Contractors as to their business classification and current status. Please check all the applicable boxes below, sign and return this form with the appropriate documentation. You must provide your organization’s status and supporting documentation for inclusion on our Approved Supplier List.

Company Name:

Street Address: City: State: Zip: Product or Service: Main NAIC Code: (See www.census.gov/epcd/www/naics.html )

Preferred Phone: Fax:

E-Mail Address: Website Address: _________________________________________________________________________________________________________________Please check all applicable boxes:

Large BusinessAny business that does not meet the criteria to qualify as a small disadvantaged business concern. YES NO

Small BusinessA business that is independently owned and operated, not dominate in its field of operation; that meets the criteria and size standards specified in the code of federal regulations (13CFR part 121, see FAR 19.102). YES NO

Minority BusinessA business (large or small) physically located in the United States or its Trust Territories; at least 51% owned, controlled and operated by one or more minority group members. In the case of any public owned business, 51% of the stock is owned by one or more minority group members. Minority group members are U.S. citizens who belong to the following ethnicities: African Americans, Hispanic Americans, Native Americans (American Indians, Eskimos, Aleuts and native Hawaiians), Asian-Pacific Americans (U.S. citizens whose origins are from Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U.S. Trust Territories of the Pacific, Northern Marianas, Laos, Cambodia, Taiwan). Asian-Indian Americans (U.S. citizens whose origins are from India, Pakistan and Bangladesh). YES NO(If yes, please note applicable certification and include a copy of the certification).

Certification with regional Minority Supplier Diversity Council Other ________________________________________________

Small disadvantaged business concernis is not certified by the Small Business Administration as a small disadvantaged business concern and identified, on the date of this representation, as a certified small

disadvantaged business concern in the database maintained by the Small Business Administration (Dynamic Small Business Search), and that no material change in disadvantaged ownership and control has occurred since its certification, and, where the concern is owned by one or more individuals claiming disadvantaged status, the net worth of each individual upon whom the certification is based does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104©(2); or

does does not self-certify as a small disadvantaged business concern where the concern is owned by one or more individuals claiming disadvantaged status, the net worth of each individual upon whom the certification is based does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104©(2).

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Certification

Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number.

PRINT NAME: CARLOS VALENCIA_________ TITLE: Police Office___________

SIGNATURE: Carlos Valencia__________ DATE: 05/06/13_______________

Women-Owned BusinessA business that is at least 51% owned by one or more women and whose management and daily business operations are controlled by one or more women. YES NO (If yes, include any certifications)

HubZoneSmall businesses located in “historically under-utilized” business zones (areas of high and persistent unemployment). Not only must the business be located in one of these “zones”, but also at least 35% of the employees must reside in a zone. To qualify as a HubZone business, the U.S. Small Business Administration must certify the company. YES NO

Veteran-OwnedSmall businesses in which 51% of the ownership is held by one or more Veterans (as defined in 38 U.S.C. 101(12) or, in the case of any publicly owned business, 51% or more of the stock is owned by one or more Veterans; and the management and daily business operations are controlled by one or more Veterans. YES NO

Service-Disabled Veteran Small BusinessBusinesses owned by a Veteran or Veterans (see above). To be further classified as Service-Disabled in accordance with 38 U.S.C. 10(12), the Veteran or Veterans must have a disability/or disabilities that are Service connected as defined in 38 U.S.C. 101(16). YES NO

Lesbian Gay Bi-Sexual Transgender Owned BusinessA business that is at least 51% owned by one or more LGBT and whose management and daily business operations are controlled by one or more LGBT. YES NO

Certification is required by an authorized representative verifying the information submitted is true. In accordance with 15 U.S.C 645(d), any person who misrepresents a firm’s proper size classification shall (1) be punished by imposition of a fine, imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act.

Authorized Signature and Title: Date:

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