Vendor Information Form printable pdf download

VENDOR INFORMATION FORM

You may complete the following Vendor Information Form by printing out the form, completing the

appropriate information along with signature, and submit your application by mail or fax.

Mailing/Order Address:

Remittance Address: (If different)

Company Name:

______________________________

Address:

______________________________

Contact Person:

_________________________

__________________________

Telephone No:

_________________________

__________________________

Fax No:

_________________________

__________________________

e-mail:

_________________________

__________________________

The undersigned certifies that the information contained herein is correct. I understand that the form must be complete or

it will be returned. Vendors are added to the file based on the information contained in this form. Misrepresentation may

be cause for removal of my firm's name from the Town's vendor list.

Signed:

______________________________________

Title:

________________________

Above signature (typed):

______________________

Date: ________________________

Check those that apply to your firm:

____ Minority owned (at least 51%)

Is your firm incorporated?

_____ (Y/N)

____ Female owned (at least 51%)

____ Physically handicapped owned (at least 51%)

What is your Federal Identification Number or Social Security Number? _________________________

Are you a governmental or a not-for-profit entity? _____ (Y/N)

What is the nature of your business? Strictly sale of merchandise

_____ (Y/N)

Provider of services, including parts/supplies

_____ (Y/N)

Town of Cary Privilege License Number _______________ Not yet applied for ______________ (ü)

Exempt for reasons of:______________________________________________________________

After placement on our vendor lists, a vendor's repeated failure to respond to the Town's inquiries in kind (submission of written

response if written request was sent or responding by telephone if the inquiry was made by telephone) either to bid or to advise that

your firm is unable to bid will be understood by the Town of Cary to indicate a lack of interest and your concurrence in the removal of

your firm's name from the Town's vendor lists.

Please check the goods and services that are listed on the following page that your firm would be interested in supplying and return

this form to:

Town of Cary

Purchasing Division

P. O. Box 8005

Cary, NC 27512-8005

Telephone: 919-469-4105 // Fax: 919-469-4377

Vendor Information Form

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