12-16. NEW VENDOR FORM.docx
DOCX document 51 KB Posted
- Attached to
- Medical and Pharmacy Benefits
- Solicitation number
- 26001
- Issued by
- Maricopa County, Scottsdale City, Arizona
About this file
The document is a New Vendor Form from Scottsdale Unified School District #48 (SUSD) in Arizona, specifically related to Request for Proposal (RFP) #26001 for Medical and Pharmacy Benefits. The form is designed for potential vendors to register and provide essential company information, with a submission deadline of October 15, 2025. The RFP seeks to evaluate the current health benefit programs, focusing on cost competitiveness, service capabilities, employee satisfaction, and compliance.
The vendor form requires comprehensive company details, including legal name, contact information, payment details, and unique entity identification. Vendors must acknowledge several key requirements, such as compliance with state and federal non-discrimination statutes, understanding that the form does not guarantee contract award, and agreeing to provide services only with an authorized SUSD Purchase Order. The form mandates that vendors submit invoices directly to SUSD Accounts Payable, include the Purchase Order number on all invoices, and include a copy of their W-9 form. Critical vendor disclosures include declarations about potential conflicts of interest, such as being a SUSD employee or having relatives on the governing board.
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Text version
Scottsdale Unified School District #48 New Vendor Form
Purchasing Department 9313 N. 95th Way Scottsdale, AZ 85258 480-484-6151
RFP #: 26001
PROJECT: MEDICAL AND PHARMACY BENEFITS
| ORDER INFORMATION |
| PAYMENT INFORMATION |
| LEGAL NAME OF ORGANIZATION / INDIVIDUAL |
| LEGAL NAME OF PAYEE |
| STREET ADDRESS |
| STREET ADDRESS |
| STREET ADDRESS 2 |
| STREET ADDRESS 2 |
| CITY |
| CITY |
| STATE |
| ZIP |
| STATE |
| ZIP |
| PHONE NUMBER W/ EXTENSION |
| FAX NUMBER |
| PHONE NUMBER W/ EXTENSION |
| FAX NUMBER |
| CONTACT NAME |
| CONTACT NAME |
| EMAIL ADDRESS FOR PURCHASE ORDERS (required) |
| EMAIL ADDRESS FOR ACCOUNTS RECEIVABLE (required) |
| WEB ADDRESS | |
| DOES YOUR COMPANY ACCEPT PURCHASE ORDERS? | |
| YES | NO |
UNIQUE ENTITY ID (formerly DUNS Number)
ARE YOU A SUSD EMPLOYEE?
YES NO IF YES, EXPLAIN:
LOCAL REPRESENTIVE NAME
RELATIVE OF SUSD EMPLOYEE?
| LOCAL REPRESENTATIVE CONTACT PHONE | ||
| YES | NO | IF YES, EXPLAIN: |
MEMBER OR RELATIVE OF SUSD GOVERNING BOARD?
LOCAL REPRESENTATIVE EMAIL
YES NO IF YES, EXPLAIN:
VENDOR ACKNOWLEDGEMENTS - BY SIGNING BELOW, I HEREBY ACKNOWLEDGE THAT:
1. I am duly authorized to certify the information requested herein.
2. To the best of my knowledge, the elements of the information provided herein are accurate and true as of this date.
3. My organization will comply with all State statutes and Federal equal opportunity and non-discrimination requirements and conditions of employment in accordance with A.R.S. Title 41, Chapter 9, Article 4 and Executive Order Number 75-5 dated April 28, 1975.
4. Filing of a Vendor Registration Application supplies information only and does not constitute an assumed obligation by Scottsdale Unified School District (SUSD) to guarantee contractual awards or agreements to my organization.
5. Updating information contained on this form is solely the duty of my organization.
6. My organization will not provide any product or service without first having in our possession an authorized SUSD Purchase Order. No products or services will be provided based on a verbal promise of a Purchase Order or with the submission of a requisition for a Purchase Order. I understand that payment for any product or service provided without an authorized Purchase Order is not the responsibility of SUSD and that I will have to obtain payment from the individual requestor.
7. My organization will direct all communication regarding SUSD Purchase Orders to the SUSD Procurement Office.
8. My organization will provide the Purchase Order number on all invoices submitted to SUSD. I understand that invoices received without this information will not be paid.
9. My organization will submit all invoices directly to SUSD Accounts Payable and not to the requesting department or school.
| PRINTED OR TYPED NAME |
| TITLE |
| SIGNATURE |
| DATE |
Please Include a copy of your W-9 form.
RFP #: 26001 Page 1 of 1 Due: October 15, 2025 image1.png
File details come from the government source that posted it. Updated .