Supplier Registration Form

Supplier Registration Form

Instructions:

Please fill in all data requested below. In the event any fields are not applicable to your organization enter “N/A”. Should information submitted be incomplete, we may not be able to consider your firm as a contractor/supplier.

Today's Date*

Company Name*

Full Legal Entity Name

Company Name (DBA)*

If different from name above; otherwise mark N/A

Company Address*

Headquarters or Primary Business Address

Business Type*

Briefly describe the type of product or service you offer.

Do you have a Parent Company?*

Yes

No

Parent Company Name and Address

Subsidiaries/Affiliates

List all Subsidiaries and Affiliates

Website Address*

Form of Business*

Sole Proprietorship

Partnership

Corporation

S Corporation

Limited Liability Company

Years In Business*

How many years has your organization been in business under your present firm name?

Minority Ownership*

Does your company have any minority ownership/financial backing?

Yes

No

Minority Ownership Type

If yes, please specify the minority ownership type you are classified as.

MBE

WBE

LGBTQE

VBE

Do you normally employ:

Union Personnel

Non-Union Personnel

Leased Personnel

If Union Personnel, list trades/locals

D&B Number and Financial Rating*

Annual Dollar Volume for the Past Three (3) Years*

Desired Project Size*

List as MWac or MWdc

Insured*

(check if true)

Licensed*

(check if true)

Bonded*

(check if true)

Has the company, or its predecessors, or any person in an official capacity with the company, ever been adjudicated bankrupt; ever failed to complete a contract; or ever made an assignment of assets in settlement of business obligations for less than the total amount of the indebtedness?*

Yes

No

If "Yes", please attach details below under File Attachments

Are there now any liens, suits, or judgements pending or outstanding, and unsatisfied as a result of the business operations or the company, its officers, or its predecessors?*

Yes

No

If "Yes", please attach details below under File Attachments

License No.

Point of Contact*

Contact Title*

Contact E-mail*

Contact Phone No.

Contact Fax No.

Additional Information

Acknowledgement of Terms*

I hereby affirm that all information supplied is true and accurate to the best of my knowledge and belief, and I understand that this information will be considered material in the evaluation of quotations, bids, and proposals. Notice must be given of any change in status impacting the information provided within ten (10) days of said change. Checking the box below signifies that you agree.

Name of Person Agreeing to Terms*

Must be a company officer.

Date Agreed to Terms*

Select today's date.

File Attachments

Please provide copies of items below with your SPF submission:

Most recent Audited Financial Statement, Including Balance Sheet & Income Statement
Statement of Qualifications
Past Projects and Customer References (if not included under bullet 2)

Drag and drop files here or

Send me a copy of my responses

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