1. Company Name & Bid Address (Info will be verified 2. Address to which payments are to be mailed (if same against IRS records & vendor name) as #1, leave blank) 3. Telephone (toll free) 4. Telephone (other) 5. Fax 6. Name of Contact Person 8. Company URL 7. Address of Contact Person 9. Federal Identification Number (FEIN) 10. Social Security Number (if no FEIN) Note: Company name must match IRS records 11. Type of Organization one) 12. Kind of Ownership (Check all that apply): Individual Foreign Individual ☐ ☐ Partnership Medical/Health Corp ☐ ☐ State of Incorporation: Year of Incorporation: 13. Minority Ethnicity Code (Check One): 14. Preference for reporting purposes: African American (MA) Native American (MN) Small Minority Woman-Owned □ □ □ □ □ Hispanic American (MH) Asian American (MS) □ □ Service-Disabled Veteran Disabled-Owned □ Other Minority (MO) Specify: ____________________ □ 15. Type of Business (Check one): 16. Number of Employees Agriculture, Forestry, Fishing Construction □ □ Marketing/Communications/Public Relations 17. Excluded from Federal Procurement or □ Nonprocurement Programs? Yes No Architectural/Design/Engineering Educational □ □ Medical/Healthcare Manufacturing □ □ Mining Retail □ □ 18. Annual Gross Sales Finance, Insurance & Real Estate Service Industry □ □ Information Systems/Technology Wholesale □ □ Transportation, Commerce & Utilities □ 19. Commodities: List goods and services for which your company wishes to receive bid opportunities. If additional space is needed please attach a separate sheet to the vendor application. 20. * SECTION A SECTION B – – CONTRACTOR IS AN INDIVIDUAL CONTRACTOR IS A COMPANY (e.g. sole proprietorship, partnership, or corporation)
1. Company Name & Bid Address (Info will be verified against IRS records & vendor name) 2. Address to which payments are to be mailed (if same as #1, leave blank) 3. Telephone (toll free) 4. Telephone (other) 5. Fax 6. Name of Contact Person 7. Address of Contact Person 8. Company URL 9. Federal Identification Number (FEIN) Note: Company name must match IRS records 10. Social Security Number (if no FEIN) 11. Type of Organization one) ☐ Individual ☐ Foreign Individual ☐ Partnership ☐ Medical/Health Corp State of Incorporation: Year of Incorporation: 12. Kind of Ownership (Check all that apply): 13. Minority Ethnicity Code (Check One): □ African American (MA) □ Native American (MN) □ Hispanic American (MH) □ Asian American (MS) □ Other Minority (MO) Specify: ____________________ 14. Preference for reporting purposes: □ Small □ Minority □ Woman-Owned Service-Disabled Veteran □ Disabled-Owned 15. Type of Business (Check one): □ Agriculture, Forestry, Fishing □ Construction □ Marketing/Communications/Public Relations □ Architectural/Design/Engineering □ Educational □ Medical/Healthcare □ Manufacturing □ Mining □ Retail □ Finance, Insurance & Real Estate □ Service Industry □ Information Systems/Technology □ Wholesale □ Transportation, Commerce & Utilities 16. Number of Employees 17. Excluded from Federal Procurement or Nonprocurement Programs? Yes No 18. Annual Gross Sales 19. Commodities: List goods and services for which your company wishes to receive bid opportunities. If additional space is needed please attach a separate sheet to the vendor application. 20. * SECTION A – CONTRACTOR IS AN INDIVIDUAL SECTION B – CONTRACTOR IS A COMPANY (e.g. sole proprietorship, partnership, or corporation)
vendorapp7_6_18.docx