Roanoke City Public Schools Purchasing and Financial Control 40 Douglass Avenue Roanoke, VA (540) Fax (540)

Transcription

1 Roanoke City Public Schools Purchasing and Financial Control 40 Douglass Avenue Roanoke, VA (540) Fax (540) Vendor Application Form Ladies and Gentlemen: If you wish to be listed on the Roanoke City Public Schools bid/proposal notification list you should complete the following form and return it to the Department of Purchasing and Contract Services. Section 1 Date: 1. Legal Name of Company or Corporation: 2. Corporation Partnership Individual Other 3. State of Incorporation: Taxpayer ID: PROCUREMENT ADDRESS: 4. Street Address: PO Box 5. City: State: Zip: 6. Telephone Number: Toll-Free Number: 7. Fax Number: PAYMENT ADDRESS: 8. Street Address: PO Box 9. City: State: Zip: 10. Telephone Number: Toll-Free Number: 11. Fax Number: Name of Nearest Local Representative: 13. Mailing Address: 14. Telephone Number: Toll-Free Number: 15. Fax Number: Address:

2 Section II 1. Indicate names and titles of principal officers: A. B. C. D. 2. Financial Data: A. Have you ever been refused a bid or performance bond? If yes, please explain: B. Indicate two bank references: 1. Bank Name: Address: 2. Bank Name: Address: Section III Contact Information: Order Placement Order Delivery Claims Dept. Pricing Information Invoicing Engineering Matters Terms of Pmt. Sales Manager President NAME TELEPHONE # ADDRESS (IF DIFFERENT FROM PG 1 )

3 Section IV Please indicate three local or state governmental agencies in the State of Virginia with which you have done business in the last three years: 1. Agency Name: Address: Contact Person: Telephone # 2. Agency Name: Address: Contact Person: Telephone # 3. Agency Name: Section V Address: Contact Person: Telephone # 1. Is this a minority business enterprise as defined by the State Office of Minority Business Enterprise? YES NO Please check one: White Black Hispanic American Indian Asian Other If Other please explain: Please check all that apply: Minority Owned Small Business Woman Owned Business Minority/Women Owned Veteran Owned Business 2. Does your business qualify as a small business as defined by the United States Small Business Administration? YES NO If yes, please explain:

4 Section VI Please complete attached copy of W-9 and return with your Vendor Application. Section VII Commodity Codes Please check all areas that apply. GROUP NAME COMMODITY CODE GROUP CODE ACCOUNTING SERVICES ACCT SVCS ACOUSTIC WALL PANELS ACOUSTIC AIR DUCT CLEANING AIR DUCT CLN AIRCRAFT AIRCRAFT ALARMS-FIRE/SEC - INSTALL ALARMS-FIRE/SEC ALARMS-MONITOR FIRE/SEC ALARMS-MONITOR ARCHITECTURAL SERVICES ARCH SVCS ASBESTOS REMOVAL ASBESTOS-REM BAKERY EQUIPMENT MAINT. & REPAIR EQU REPAIR BKRY BEVERAGE SERVICE 39377, 74085, BEVERAGE SVC BUILDING RENOVATIONS BLDG RENOV BLEACHERS, RISERS BLEACHERS BOILER REPLACEMENT BOILER REPL BOILER SALE BOILER SALE BUS PARTS BUS PARTS BUS ROUTING SYSTEM BUS RT SYS BUSES-SCHOOL BUSES SOFTWARE-BUSINESS MISC BUSINESS MISC CABINETRY CABINETS CARPENTRY CARPENTRY CARPET CARPET CARPET CLEANING CARPET CLEANING COMPUTER CONSULTANT 91828, 91829, COMP CONSULT COMPUTER EQUIPMENT 20400, COMP EQ COMPUTER NETWORKS 20400, COMP NETWORKS COMPUTER SOFTWARE 20800, COMP SOFTWARE COMPUTERIZED SYSTEM-FD SVCS COMP SYS-FD SVC CONCRETE CONCRETE CONSTURCTION MANAGEMENT SVCS CONST MGMT CONSULTANT - TELEPHONE SVCS CONSULT-PHONE COPY MACHINE COPIER CURTAINWALL CURTAINWALL DEMOLITION DEMOLITION DITCHING & EXCAVATING DITCHING DRIVER EDUCATION TRAINING 99032, DR ED DRUG CARD - PRESCRIPTION DRUG CARD DRY WALL DRY WALL DUMPSTER SERVICES DUMPSTER SVCS ELECTRICAL SERVICE ELEC SVC ELECTRONICS ELECTRONICS EMPLOYEE CLASSIFICATION STUDY EMPLOYEE STUDY ENGINEERING SERVICES ENG SVCS EQUIPMENT - AUDIO VISUAL 84000, EQ-A-V EQUIPMENT - FOOD SERVICES 16500, 74070, EQ-FD SVS EQUIPMENT - HVAC 03100, EQ-HVAC EQUIPMENT - MOWING EQ-MOWING EQUIPMENT - OFFICE EQ-OFF

5 EQUIPMENT - PHYSICIAL EDUCATION EQ-PE EQUIPMENT - PLAYGROUND EQ-PLAYGROUND CAFETERIA & KITCHEN EQUIP. REPAIR EQU REPAIR CAFÉ EQUIPMENT - SCIENCE EQ-SCIENCE EQUIPMENT - VOCATIONAL EDUCATION EQ-VOC ED EXTERMINATING SERVICES 91059, EXTERMINATING FENCES FENCES FLOORS-HARDWOOD FLOORS FOOD-FROZEN, STAPLE, CANNED 38500, 39000, FOOD FOOD-BAKERY PRODUCTS FOOD-BAKERY PRO FOOD-ICE CREAM & DAIRY PRODUCT 38045, FOOD-IC & DIARY FOOD-SNACK FOODS 39310, 39343, FOOD-SNACK FURNITURE-CAFETERIA FURN-CAF FURNITURE-CLASSROOM FURN-CLASS FURNITURE-LIBRARY 42056, FURN-LIB FURNITURE-OFFICE FURN-OFFICE GENERAL CONTRACTOR 91200, 91300, GEN CONT GRADING GRADING HAULING HAULING HVAC HVAC HVAC FILTERS 03144, HVAC FILTERS INSURANCE-ACCIDENT INS-ACC INSURANCE-ANNUITIES INS-ANN INSURANCE-AVIATION INS-AVIATION INSURANCE-CONSULTING FIRMS INS-CONSULTANT INSURANCE-DENTAL INS-DENTAL INSURANCE-EXCESS WORKER'S COMP INS-EX WK COMP INSURANCE-FLEET 95330, 95333, INS-FLEET INSURANCE-FLEXIBLE BENEFITS INS-FLEX BENE INSURANCE-HEALTH INS-HEALTH INSURANCE-LIABILITY INS-LIAB INSURANCE-STUDENT INS-STUDENT INTEGRATED TECHNOLOGY SYSTEM INTEG TECH SYS INTERCOM SYSTEMS INTERCOM SYS INTERIOR DECORATORS INTERIOR DEC INVENTORY SOFTWARE INVENTORY SFTWR JANITORIAL SERVICES JANITORIAL SVC LANDSCAPING LANDSCAPING LIB CIRCULATION SYS SOFTWARE LIB SYS SOFTWRE MAGAZINE SUBSCRIPTIONS MAGAZINES MASONRY MASONRY MODULAR UNITS & BUILDINGS MOD UNITS MOWING-GRASS MOWING MUSICAL INSTRUMENTS & ACCESS MUS INST NEWSPAPER NEWSPAPER PAINT & RELATED PRODUCTS PAINT PAINTING SERVICES PAINTING SVCS PAPER-PRINTING PAPER PROD PAPER-PRODUCTS-OPERATIONS PAPER PROD-OPNS PARTITIONS 15058, PARTITIONS PAVING-ASPHALT PAVING PERSONNEL MANAGEMENT SOFTWARE PERSONNEL MNGE PIZZA - ALA CARTE 37554, PIZZA PLASTER WORK PLASTERERS PLUMBING SERVICES PLUMBING PRINTING SERVICES PRINTING SVCS PHYSICAL/OCCUPATIONAL THERAPY PT/OT RADIO SYSTEM RADIOS

6 REFRIGERATION EQUIP. MAINT. & REPAIR REFRIG. EQU REP ROOFING CONSULTANT ROOF CONSULT ROOF REPLACEMENT ROOF REPL SCHOOL PICTURES SCH PICTURES SCOREBOARD SCOREBOARDS SEARCH FIRM SEARCH FIRM SECURITY CAMERA SECURITY CAMERA SENIOR SERVICES 20167, 98364, SENIOR SERVICES 08046, SHEET METAL SHEET METAL SIDING - ALUM & VINYL SIDING SIGNS SIGNS SITE CHARACTIZATION SITE CHAR SITE IMPROVEMENTS SITE IMPROVEMNT SITE-UTILITIES SITE UTILITIES SPEECH/LANGUAGE THERAPY 96167, SPEECH SPRINKLER SYSTEM SPRINKLER SYS STAGE CURTAINS STAGE CURTAINS STEEL STEEL STUDENT ASSESSMENT STUDENT ASSESS SUPPLIES-ART SUP-ART SUPPLIES-CAFETERIA 64050, 64060, SUP-CAF 64080, 48501, 48518, SUPPLIES-CLASSROOM SUP-CLASS SUPPLIES-CLEANING 48554, SUP-CLEANING SUPPLIES-ELECTRICAL SUP-ELECT SUPPLIES-OFFICE 61000, SUP-OFFICE SUPPLIES-SCIENCE SUP-SCIENCE TECHNOLOGY ED LABORATORY TECH LAB TELEPHONE SERVICE 91576, TELE SVC TELEPHONE SERVICE-MOBILE TELE SVC-MOBILE TELEPHONE SYSTEMS TELE SYSTEMS TESTING-ENVIRONMENTAL TESTING-ENVIROM TEXTBOOKS 71585,86,87 TEXT BOOKS TILE TILE TRACTORS TRACTORS UNIFMS-CAF, OPNS, MAINT, TRANSP UNIFORMS UNIFORMS-BAND UNIFORMS-BAND VEHICLES (CARS, TRUCKS, VANS) 07000, 07048, VEHICLES 07051, WATERPROOFING WATERPROOFING WELDING WELDING WHEELCHAIR LIFT WHEELCHR LIFT WORK COMP CLAIMS AND SERVICE WK COMP OTHER:_(NIGP Code if known)

7 Form W-9 (Roanoke City School Board Substitute W-9 Form) Request for Taxpayer Identification Number and Certification Completed form should be returned to Purchasing&Financial Cont. PO Box Roanoke VA City Vendor Number if previously assigned: Name (List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2) Business name, if different from above. (See Specific Instruction on page 2) Check appropriate box: Individual Sole proprietor Corporation Partnership Other Legal Address: number, street, and apt. or suite no. Remittance Address: if different from legal address. City, state and ZIP code Remittance City, state and ZIP code Phone # Remittance Phone # Fax # Remittance Fax # Address Remittance Address Procurement Contact Person Remittance Contact Person Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note: If the account is in more than one name, see the chart on page 3 for guidelines on whose number to enter. Social security number - - Part II Certification OR Employer identification number - Sign Here Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Services (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am an U.S. person (including an U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. Authorized Signature Date Supplemental Vendor Information (Check ALL that apply): City of Roanoke Employee Roanoke City Public Schools Employee Small Business Minority Owned Business Women Owned Business Social Services Vendors Only: Day Care Provider Foster Care/Adoptive Parent Other Social Services Provider Form RKE W-9 (Rev. July 2005) 7 Vendor Application Updated 2/22/2011