Vendor Information Application Form
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9City of Berkeley
For City Use Only
Finance Department – General Services Division
Vendor
Code ____________
Vendor Information Application
Rec’d ____________
P
T
O
P
C
I
I
LEASE
YPE
R
RINT
LEARLY
N
NK
LBE
____________
Business Information (all information must be completed)
Business Name ____________________________________________ Year Est. _____ No. of Employees ______
Name (as shown on your Income tax return) _________________________________________________________
Check Payable to Name: ________________________________________________________________________
Street Address ______________________________________ City __________________ St ____ Zip _________
Remit-to Address ____________________________________ City __________________ St ____ Zip _________
Contact Person(s) _______________________________ Phone(s) ___________________ Fax _______________
Email Address ________________________________________ CA State Sales Permit No. __________________
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 if business is qualified for the City’s “Buy Berkeley” local bidding preference (5% below $25K on
goods and non professional services. 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
[ ] Individual/Sole Proprietor
[ ] L.L.C
[ ] Corporation
[ ] S Corp.
[ ] Partnership
[ ] Other (specify) __________________________________________________________________
Certification: Under penalties of perjury, I certify that the taxpayer identification number(s) all other information
provided herein are correct
_____________________________________________________________
Name (print)
_____________________________________________________ _____________ ________________________
Signature of Company Officer
Date
Phone
PLEASE NOTE: IF THERE IS NO BUSINESS CONDUCTED DURING ONE YEAR YOUR ACCOUNT WILL BE
INACTIVATED.
rev 3/2007
rd
2180 Milvia Street, 3
Fl., Berkeley, CA 94704 Tel: 510.981.7320 TDD: 510.981.6903 Fax: 510.981.7390
E-mail: finance@ci.berkeley.ca.us
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Parent category: Business