Procurement & Contract Services Supplier Registration

Procurement & Contract Services

Supplier Registration

Thank you for your interest in doing business with San Joaquin Delta Community College District. In accordance with District Policy and in order to be registered as a supplier, complete this Supplier Registration form completely. Visit the Procurement and Contract Services website for a copy of the San Joaquin Delta Community College District Purchase Order Terms and Conditions and Insurance Requirements.

Date Submitted*

BUSINESS INFORMATION

Supplier Name*

DBA (if applcable)

Business Address & Street Name*

Business Address 2 (Ste, Apt, Unit)

City*

State*

Select

Country*

United States

SUPPLIER CONTACT INFORMATION

General Contact Name*

General Contact Email*

General Contact Phone*

Phone

Business Website

Business Certification

Select or enter value

Business License

Contractor License (if applicable)

Enter number if business is a licensed contractor in the State of California.

Payment Terms

Select or enter value

Remit Address, if different

Insurance Evidence (Check box if attached)

Dept/Staff Name Requesting Supply/Service*

Select or enter name of District contact or department you are supporting.

Select or enter value

Commodity Categories

Select

File Upload*

COMPLETE, SIGN & UPLOAD FORMS TO ESTABLISH SUPPLIER PROFILE

W-9 (required)

CA Forms (as applicable) 587, 588, 589, 590

Evidence of Insurance (District Insurance Requirements)

Drag and drop files here or

SUPPLIER AGENT DECLARATION

By entering your name, you hereby declare that you are an authorized agent to submit documents on behalf of the business. Furthermore the named representative:

understands that accordance with California Assembly Bill 3678, effective January 1, 1987, that any person through its directors, officers, or agent that falsely represents a business as a women or minority business enterprise in an attempt to procure contracts is subject to fine or imprisonment.

agrees to inform San Joaquin Delta Community College of any changes to the information contained herein, particularly changes in ownership, controlling interest or operations.

further certifies that they shall not discriminate against any employee or applicant for employment because of race, color, religion, sex, age, national origin, or because they are disabled, or veteran of the Vietnam era, and shall comply with all applicable provisions of state and federal requirements regarding equal employment opportunity, affirmative action reporting and compliance programs, utilization of minority business enterprises and subcontractor programs.

if applicable, certifies workers compensation exemption. If any employee is hired, voiding the workers compensation exemption, proof of workers compensation is required to be sent to San Joaquin Delta Community College Procurement and Contract Services team within 15 calendar days.

Supplier Authorized Agent Name*

Send me a copy of my responses

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