10-Vendor Profile Information Form - 2024.docx
DOCX document 24 KB Posted
- Solicitation number
- BC-BID-26-22.1
- Issued by
- Bergen County, New Jersey
About this file
This file is a Vendor Information Form from the County of Bergen, New Jersey, Department of Administration and Finance, Division of the Treasurer. The form is a standard registration document designed to collect and verify vendor information for the county's procurement processes. The form requests comprehensive vendor details including company name, physical address, authorized official contact information, and preferred method for receiving purchase orders via email. Vendors are required to provide remittance address information if it differs from their primary business address, including a designated pay-to contact person and payment email address. The form also requires vendors to declare their business classification, including whether they operate as a sole proprietor, corporation, partnership, limited liability company, or other entity type, along with their Internal Revenue Service classification.
The form includes several diversity and socioeconomic status certifications, allowing vendors to self-identify as small businesses, minority-owned, women-owned, or veteran-owned enterprises. Additionally, vendors may indicate tax-exempt organization status if applicable. All information provided must be certified as true and accurate by an authorized representative through signature and printed name. This vendor profile form serves as a foundational registration document for participation in Bergen County procurement opportunities, including the related golf range equipment and supplies contract (BC-BID-26-22.1), which seeks multiple catalog vendors for a 24-month contract period to provide golf range equipment, accessories, repair parts, and related supplies.
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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:
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