10-Vendor Information Form.pdf
PDF 119 KB Posted
- Attached to
- Roadway Repair Materials - COOP
- Solicitation number
- BC-BID-26-26
- Issued by
- Bergen County, New Jersey
About this file
This Vendor Information Form is used by the County of Bergen Department of Administration and Finance, Division of the Treasurer, to collect essential vendor data for participation in the Roadway Repair Materials cooperative purchasing contract (BC-BID-26-26). The contract establishes a twelve-month agreement commencing July 1, 2025 through June 30, 2026, between the County of Bergen and multiple vendors to supply various roadway repair materials and products including bituminous concrete, roadway patch materials, catch basin components, manhole frames and covers, asphalt solvents, roadway plates, masonry materials, and precast concrete items. These materials will support the County of Bergen Department of Public Works and registered New Jersey Cooperative Purchasing Alliance members.
The form requires vendors to provide complete company information as it appears on their W-9 form, including legal company name, address, authorized official contact details, and preferred method for purchase order delivery. Vendors must specify their business classification, including designation as small business, minority-owned, women-owned, or veteran-owned enterprises, and identify their IRS tax classification structure. The form also allows vendors to designate a separate remittance address and payment contact information if different from their primary business address. All information provided must be certified as true and accurate by an authorized representative.
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Text version
COUNTY OF BERGEN
DEPARTMENT OF ADMINISTRATION AND FINANCE
DIVISION OF THE TREASURER
One Bergen County Plaza• Suite 501 • Hackensack, N.J. 07601-7076
(201) 336-6550 • (201 336-6595 James J. Tedesco, Ill County Executive
Jon Rheinhardt
CFO
Melissa Howard Treasurer
* - Required field
VENDOR INFORMATION FORM
Vendor Information (as displayed on W-9 form):
Company Name*:
Address*:
City*:
State*:
Zip Code*:
Name of Authorized Official*:
Phone Number*:
Email Address*:
Would you prefer that PO's to be emailed to the email address provided?
□Yes □No
Remittance Address: (if different than information above)
Pay-To-Name:
Pay-To-Address:
Pay-To-City:
Pay-To-State:
Pay-To-Zip:
Pay-to Attn:
Payment Email:
Business Classification:
Is your company a: * IRS Classification: *
□ Small Business □ Individual/ Sole proprietor
□ Minority Owned □ C-Corp
□ Women Owned □ S-Corp
□ Veteran Owned □ Partnership
□ Other: □ Trust/Estate
□ Not Applicable □ Limited Liability Corp - Corporation
□ Limited Liability Corp - S
Corporation
□ Limited Liability Corp - Partnership
□ Tax-Exempt Organization
I certify that the information provided on this form is true and accurate to the best of my knowledge.
Print Name: Signature:
File details come from the government source that posted it. Updated .