20220627 Vendor Application with DD Form.pdf

LARAMIE COUNTY SCHOOL DISTRICT NUMBER ONE

Purchasing Department 2810 House Avenue, Room 118 Cheyenne, WY 82001

FAX (307) 771-2154 Website: http://www.laramie1.org

SUPPLIER APPLICATION

This form must be completed, review and a W-9 received for LCSD1 records prior to conducting business with the District.

Certificates of Insurance naming the District as additional insured may be required and will be requested where applicable.

For additional vendor questions please contact (307) 771-2117

DATE OF APPLICATION:

Supplier’s Primary Name and Information:

Dba: __________________________________________________

Address: _______________________________________________

City, State, Zip Code: _____________________________________

Website: _______________________________________________

Phone Number: __________________________________________

Fax Number: ____________________________________________

Toll Free Number: ________________________________________

Federal ID #: ________________________________ (OR)

Social Security Number: ______________________

Type of Business:

❑ Individual ❑ Partnership ❑ Corporation ❑ LLC

State of Incorporation: ________________

❑ Wyoming Resident/In-State-Domestic Claiming Preference

Number of Years in Business: ___________

Email PO preferred: YES NO

Paper PO preferred: YES NO

Paper Check preferred: YES NO

Direct Deposit (DD) preferred: YES NO

IF YES INCLUDE DD FORM FROM NEXT PAGE.

ADDITIONAL SUPPLIER CONTACT INFORMATION:

Description Details

General

Name:___________________________

Title: ____________________________

Email: __________________________________________________________________

Address: ________________________________________________________________

Phone: __________________________________________________________________

Accounts Payable:

Name: __________________________

Title: ____________________________

Email: __________________________________________________________________

Address: ________________________________________________________________

Phone: __________________________________________________________________

Purchasing (for email of PO’s):

Name: __________________________

Title: ____________________________

Email: __________________________________________________________________

Address: ________________________________________________________________

Phone: __________________________________________________________________

Returns

Name: __________________________

Title: ____________________________

Email: __________________________________________________________________

Address: ________________________________________________________________

Phone: __________________________________________________________________

BY: ___________________________________________________ _____________________________

SIGNATURE – AUTHORIZED AGENT DATE

PURCHASING DEPARTMENT USE ONLY

Date Received: _____________ Date Entered: ______________ No.: _______________ Input by: ______________

W-9 Received: YES NO FEDERAL DEBARMENT CHECK YES NO IRS 1099 ONLY YES NO

VENDOR PROVIDES: ______ GOOD/SERVICES/BOTH OR ______ CONSULTANT/SPEAKER ONLY OR _____ REIMBURSEMENT ONLY

Revised 6/27/22 http://www.laramie1.org/

Direct Deposit Agreement Form

Authorization Agreement hereby authorize Laramie County School District #1 to initiate

(name of vendor) automatic deposits to the account of the financial institution named below.

Further, vendor agrees not to hold Laramie County School District #1 responsible for any delay or loss of funds due to incorrect or incomplete information supplied by vendor or by vendor financial institution or due to an error on the part of vendor financial institution in depositing funds to vendor account.

This agreement will remain in effect until Laramie County School District #1 receives a written notice of cancellation from vendor or vendor financial institution, or until vendor submits a new direct deposit form to the Finance Department.

Transaction type

□New Setup □Cancellation □Change financial information

Vendor Information

Name of Vendor:

LCSD#1 Vendor Number (District Use Only)

Address:

Phone:

Contact Name and

Number:

E-mail:

Please Specify how invoices will be sent:

Account Information

Name of Vendor

Financial

Institution:

Routing Number:

Account Number:

Checking

Savings

Signature

Authorized Vendor Signature and

Title (Primary):

Date:

Authorized Vendor Signature and

Title (Joint):

Date:

Finance Department

2810 House Avenue

Cheyenne, WY 82001

(307) 771-2156

BIDS/PROPOSALS

Active vendor participation is expected. I represent and warrant that the information set forth above is complete and accurate in all respects. I authorize Laramie County School District Number One to make such investigation of this company, and the information contained on this application, as necessary. I hereby certify that I have reviewed the following regulations as they relate to the Procurement Policies of Laramie County School District Number One and agree to abide by these regulations:

• There are no Laramie County School District Number One employees associated with this firm.

• My firm has been in business at least one (1) year.

• My firm is the size adequate to handle a typical order in the area in which it wants to bid.

• My firm has shown through references a satisfactory record of doing business with companies or governmental agencies in this area.

• My firm will not process orders without a purchase order or Pcard. Verbal approvals or orders with requisition numbers are not permitted.

• My firm understands that competitive bids will be required, to the extent possible, for purchases with a total value over $50,000 and plans to respond to each formal Invitation to Bid in order to protect our status as an active vendor. My firm also understands that failure to respond three times and my firm may be removed from the bid list.

• My firm will ship all orders as instructed per the purchase order or instructions from the district purchasing office.

• Representatives from my firm will not make vendor visits to District buildings, including school locations, without the expressed consent from the District Purchasing Office; and

• Representatives of my firm will, at all times, comply with the District’s requirement for ethical behavior including the prohibition of collusive and restraint of trade practices as well as providing gifts or in-kind services to employees of the District.

• My firm will comply by the definition of resident (In-State/Domestic) as follows:

a. Any person who has been a bona fide resident (In-State/Domestic) of the state of one (1) year or more immediately prior to bidding upon the contract; or

b. A partnership or association, each member of which has been a bona fide resident (In-State/Domestic) of the state for one (1) year or more immediately prior to bidding upon the contract; or

c. A corporation organized under the laws of the state with over fifty percent (50%) of its shares owned by persons who have been bona fide residents (In-State/Domestic) of the state for one (1) year or more prior to bidding upon the contract, and which maintains its principal office and place of business within the state; or

d. A corporation organized under the laws of the state, which has been in existence in the state for one (1) year or more immediately prior to bidding upon the contract and maintains its principal office and place of business within the state. If over fifty percent (50%) of its shares are owned by non-residents (In-State/Domestic), share of the corporation shall:

e. Have been acquired by nonresidents (Out-of-State/Foreign) one (1) year or more immediately prior to bidding upon the contract; or

f. Be publicly traded and registered under Sections 13 or 15(d) of the Securities Exchange Act of 1934 and one

(1) for more classes of its shares.

• Resident (In-State/Domestic) printer means any person, partnership, corporation or association who has been a bona fide resident of this state, for one (1) year or more immediately prior to bidding upon a contract, and who has an established printing plant in actual operations.