11-Vendor Information Form (fillable).pdf

Vendor Information Form

1) Prime ____ Sub-contractor _____ (This form must be completed by and for each).

2) Name of Firm:____________________________________________________________________

Telephone: ______________________________________________________________________

Fax: ____________________________________________________________________________

3) Street Address, City, State, Zip:______________________________________________________

4) E-mail Address: __________________________________________________________________ E-mail is our preferred method of contact; please correspond by same.

5) Identify Principals/Partners in Firm

Name Title % of Ownership

6) Identify the individual(s) who will act as project manager, along with other supervisory personnel on the engagement team working the HHA contract.. (Do not duplicate any resumes required above):

Name Title

7) Diversity Statement: Check all of the following that apply to the ownership of your firm, entering the percentage (%) of ownership of each:

Caucasian Public-Held Government Non-Profit

American (Male) Corporation Agency Organization

8) Minority- (MBE) or Woman-Owned (WBE) Business Enterprise (Qualifies by virtue of 51% or more ownership and active management by one or more of the following):

African Native Hispanic Asian/Pacific Hasidic American American American American Jew

Asian/Indian Woman-Owned Woman-Owned Disabled Other (Specify):

American (MBE) (Caucasian) Veteran ______________

WMBE Certification Number: ___________________________________________________________

Certified by (Agency): _________________________________________________________________

(NOTE: A CERTIFICATION/NUMBER IS NOT REQUIRED; ENTER IF AVAILABLE)

9) Are you a Section 3 Business Concern:________________________________________________ For clarification of a Section 3 Business Concern, please refer to the HHA Website listed below.

10) Federal Tax ID Number:____________________________________________________________

11) Pennsylvania Business License Number:_______________________________________________

12) State of ______ License Type and Number:____________________________________________

13) Worker’s Compensation Insurance Carrier: ____________________________________________

Policy Number: _________________________________ Expiration Date: ___________________

14) General Liability Insurance Carrier: ___________________________________________________

Policy Number:__________________________________ Expiration Date: ____________________

15) Professional Liability Insurance Carrier: _______________________________________________

Policy Number: __________________________________ Expiration Date: ____________________

16) Debarred Statement: Has this firm, or any principal(s), ever been debarred from providing any services by the

Federal Government, any state government, or any local government agency within or out the State of Pennsylvania? Yes No If "Yes," please attach a full detailed explanation, including dates, circumstances and current status.

17) If your firm currently holds any State or Federal Contracts, please list all contract #s. (i.e. CoStars, DGS Contracts, GSA Schedule 70 or 84, US Communities, WSCA, etc

18) Please provide a list of services this firm provides.

19) Would your company be interested in receiving Direct Deposit Payment from HHA? Yes No

20) Verification Statement: The undersigned proposer hereby states that by completing and submitting this form, he/she verifies that all information provided herein is, to the best of his/her knowledge, true and accurate, and agrees that if the HHA discovers any information entered herein is false, that shall entitle the HHA to not consider nor make award or to cancel any award with the undersigned party.

Signature Date Printed Name Company

Please provide current copies of all your insurance policies, Section 3 Self Certification forms, licenses, etc.

This form along with HHA Policies are available at www.harrisburghousing.org.