11-Vendor Information Form - 2024.pdf
PDF 119 KB Posted
- Solicitation number
- BC-BID-26-14
- Issued by
- Bergen County, New Jersey
About this file
This is a Vendor Information Form from the County of Bergen, New Jersey, Department of Administration and Finance, related to a 24-month contract opportunity for first responder emergency medical equipment and supplies. The contract is designed to establish relationships with multiple catalog vendors to serve the Bergen County Department of Public Safety and members of the New Jersey Cooperative Purchasing Alliance. The contract term is scheduled to commence on or about July 1, 2026, and continue through June 30, 2028, creating a cooperative pricing system available to authorized participants.
The Vendor Information Form requires prospective vendors to provide standard business registration details, including company name, address, authorized official contact information, and preferred communication methods for purchase orders. Vendors must specify their business classification, including whether they are small businesses, minority-owned, women-owned, or veteran-owned enterprises, and identify their IRS classification status. The form requests remittance address information if different from the primary vendor address and certifies that all provided information is accurate and complete.
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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 .