Name of Business*

Business Address*

City*

State*

Zip Code*

Address to which bid request and other information is to be mailed*

Invoice and payment address

Prompt Payment Discounts

Contact Information

Name*

Title

Telephone

Fax Number

Email Address*

Federal Tax I.D. Number or SSN if an individual*

Commodities / Services Provided: (Using the list of City Commodity and service codes provided please list below all codes that pertain to the Supplies, materials, and/or services your company provides

[Commodity List]

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Indicate if business is a Minority Business Enterprise (MBE), Small Business Enterprise (SBE), or a Women Owned Business Enterprise (WBE) by checking type of minority status

MBE

SBE

WBE

N/A

If you checked MBE, SBE, or WBE above, check the designation below

Hispanic (H)

Asian American (A)

Caucasian (C)

Native American (N)

Other (O)

Black (B)

Number of years in business with present business name providing the good/services.

Number of years in business with other business name providing the good/services.

The undersigned hereby certifies that the above and foregoing information is a complete, true, and correct statement of the facts.

Authorized Signature*

Print Name*

Title

Date