ATTACHMENT 6.12 Vendor Application Form Mailing Address: Tennessee State University Telephone: (615) 963-5181 Office of Procurement Services Facsimile: (615) 963-5192 3500 John A. Merritt Boulevard Nashville, Tennessee Complete all information and submit for inclusion www.tnstate.edu/procurement of your company for invitations to bid. 1. 2. Company Name and Bid Address Address to which payments are to be mailed. (If same as No. 1, leave blank.) 3. 4. Telephone (other): Telephone: 5. 6. Fax: Name of Contact Person: 7. 8. Email Address of Contact Person: Company URL (website): 9. 10. Federal Identification Number (FEIN): Social Security Number (If no FEIN): 11. 12. Type of Organization (select one): Kind of Ownership (check all that apply): Individual Government (GO) Partnership Non-Profit (NO) Non-Profit Organization Majority (MJ) Corporation Minority (MN) State of Incorporation: ______________ Woman (WO) Year of Incorporation: ______________ Small (SM) Service-Disabled Veteran (SDV) 13. 14. Minority Ethnicity Code (select one): Annual Sales (select one): African American (MA) $0 - $499,999 Native American (MN) $500,000 - $749,999 Hispanic American (MH) $750,000 - $999,999 Asian American (MS) $1,000,000 - $1,999,999 $2,000,000 and over 15. Type of Business (select one): Agriculture/Forestry/Fishing 16. Number of Employees: __________ Architectural/Design/Engineering Finance/Insurance/Real Estate Marketing/Communications/Public Relations 17. Excluded from federal procurement or Transportation/Commerce/Utilities non-procurement programs? Yes No Medical/Healthcare 18. Information Systems/Technology Preference for reporting purposes (select one): Educational/Manufacturing/Service Industry Small Woman-Owned Mining/Retail Trade/Wholesale Trade Minority Service-Disabled Veteran _____________________ Tennessee University is an Equal Opportunity/Affirmative Action University.
ATTACHMENT 6.12 Vendor Application Form Mailing Address: Tennessee State University Telephone: (615) 963-5181 Office of Procurement Services Facsimile: (615) 963-5192 3500 John A. Merritt Boulevard Nashville, Tennessee Complete all information and submit for inclusion www.tnstate.edu/procurement of your company for invitations to bid. 1. Company Name and Bid Address 2. Address to which payments are to be mailed. (If same as No. 1, leave blank.) 3. Telephone: 4. Telephone (other): 5. Fax: 6. Name of Contact Person: 7. Email Address of Contact Person: 8. Company URL (website): 9. Federal Identification Number (FEIN): 10. Social Security Number (If no FEIN): 11. Type of Organization (select one): 12. Kind of Ownership (check all that apply): Individual Partnership Non-Profit Organization Corporation State of Incorporation: ______________ Year of Incorporation: ______________ Government (GO) Non-Profit (NO) Majority (MJ) Minority (MN) Woman (WO) Small (SM) Service-Disabled Veteran (SDV) 13. Minority Ethnicity Code (select one): 14. Annual Sales (select one): African American (MA) Native American (MN) Hispanic American (MH) Asian American (MS) $0 - $499,999 $500,000 - $749,999 $750,000 - $999,999 $1,000,000 - $1,999,999 $2,000,000 and over 15. Type of Business (select one): Agriculture/Forestry/Fishing Architectural/Design/Engineering Finance/Insurance/Real Estate Marketing/Communications/Public Relations Transportation/Commerce/Utilities Medical/Healthcare Information Systems/Technology Educational/Manufacturing/Service Industry Mining/Retail Trade/Wholesale Trade _____________________ 16. Number of Employees: __________ 17. Excluded from federal procurement or non-procurement programs? Yes No 18. Preference for reporting purposes (select one): Small Woman-Owned Minority Service-Disabled Veteran Tennessee University is an Equal Opportunity/Affirmative Action University.
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