State Of New Hampshire Vendor Application - Nh State Parks
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1
2State of New Hampshire
VENDOR APPLICATION
VENDOR # ____________
(Assigned by Purchase & Property)
NAME/LOCATION
Vendor Name:
_________________________________________________________________________________
DBA Name:
_________________________________________________________________________________
LEGAL Name:
_________________________________________________________________________________
Remit Address:
_________________________________________________________________________________
City/Town:
_______________________________________
STATE: _________
ZIP: ___________
Business Address:
_________________________________________________________________________________
City/Town:
_______________________________________
STATE: _________
ZIP: ___________
Telephone #: ____________________
Toll Free #: _____________________
FAX #: ________________________
Website:
________________________________
E-Mail (Main Office):
_______________________________
Electronic Payment Option: Please contact Treasury at
treasury@treasury.state.nh.us
or visit their website at
for further information on this option. See attached ACH Form also.
TYPE OF BUSINESS
(Note: Registration with the NH Secretary of State MUST be done prior to the awarding of any contracts)
INDIVIDUAL/SOLE-PROPRIETOR
PARTNERSHIP/LLP
CORP
LLC
ESTATE OR TRUST
HEALTHCARE/LEGAL SVS
GOV
NONPROFIT
Registered with NH Secretary of State? ________________
State Incorporated In: __________________________
Minority Institutions
Minority Owned Large Business
Minority Owned Small Business
Disabled Veteran Business
Svs Disabled Veteran Owned
Veteran Owned Small Business
Physically Challenged Bus
SBA Cert Fin Disadvantaged Bus
SBA Cert Hist Underutilized Bus
SBA Cert Sm Disadvantaged Bus
Women Owned Sm Bus
Women Owned Large Businesses
Fed ID # (EIN/FIN): _______________________
Historically Black Colleges
Small Business
Social Security # (SSN): ____________________
SIGNATURE BLOCK
I certify the above information to be correct and grant authorization to the State of New Hampshire to investigate any and all facts contained therein,
including facility visitation.
Name and Title (print or type): ____________________________________________________________________________
Signature: ____________________________________________________
Date: __________________________________
ADDRESS BLOCK
DIVISION OF PLANT & PROPERTY MANAGEMENT
BUREAU OF PURCHASE & PROPERTY
(Phone) 603-271-2201
STATE HOUSE ANNEX – ROOM 102
(FAX) 603-271-2700
25 CAPITOL STREET
CONCORD NH 03301
prchweb@nh.gov
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