Vendor Information Application Form - City Of Berkeley Finance Department - 2002

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City of Berkeley
For City Use Only
Finance Department – Purchasing Division
Vendor
No.
____________
Vendor Information Application
Rec’d ____________
LBE
____________
P
T
O
P
C
I
I
LEASE
YPE
R
RINT
LEARLY
N
NK
Business Information (all information must be completed)
Company Name _________________________________________ Year Est. _____ No. of Employees _________
Street Address ____________________________________ City _____________ St ____ Zip ________________
Remit-to Address __________________________________ City _____________ St ____ Zip ________________
Contact Person(s) _______________________________ Phone(s) ___________________ Fax _______________
Email Address ________________________________________
Federal Tax I.D. No. _______________________________ or Social Security No. ___________________________
State Tax I.D. No. ________________________ City of Berkeley Business License No. ______________________
Prompt Payment Discount _____%
Number of Days _____
Net _____
Days _____
Please check appropriate box(es) if business is Minority/Female Owned:
[ ] Female
[ ] African-American
[ ] American Indian/Alaskan Native
[ ] Asian-American
[ ] Hispanic
[ ] Other
[ ] Please check if business is qualified for the City’s “Buy Berkeley” local bidding preference
(The business has a fixed office or distribution point within the City and a City Business License.)
Important: Indicate on the following pages those products and supplies the firm wishes to supply to the City.
Company Ownership
[ ] Sole Proprietorship
[ ] L.L.C
[ ] Corporation
[ ] S Corp.
[ ] Partnership
[ ] Other (specify) ____________________________
If Sole Proprietorship, please provide the owner’s name ____________________________________
Certification: Under penalties of perjury, I certify that the taxpayer identification number(s) and all other information
provided herein are correct.
_______________________
___________________________
__________
________________
Name (print)
Signature of Company Officer
Date
Phone
rev 5/2002-F
rd
2180 Milvia Street, 3
Fl., Berkeley, CA 94704 Tel: 510.981.7320 TDD: 510.981.6903 Fax: 510.981.7390
E-mail:purchasing@ci.berkeley.ca.us

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