23054i_attachment09.pdf
PDF 56 KB Posted
- Attached to
- Protective Outerwear
- Contract number
- 23054
- Issued by
- New York
About this file
This document is an "Authorized Dealer/Distributor Information" form, which appears to be part of a state contract vehicle for New York State (NYS). The form provides a template for listing multiple dealers and distributors, with space for up to 10 different companies to be registered under a specific contract. The form is designed to capture key details about each dealer/distributor, including company name, contact information, federal and NYS vendor identification numbers, and their authorized capabilities.
The form includes sections for dealers/distributors to indicate their authorization for activities such as taking orders, shipping directly, receiving payments, and providing Shoemobile (Truck) Services. Additionally, the document allows companies to self-identify as NYS certified Minority and Women-owned Business Enterprises (M/WBE) or Service-Disabled Veteran-Owned Businesses (SDVOB), which may provide certain contracting advantages. Each dealer/distributor entry has a field for "Qualifying Criteria Applicable to this Dealer/Distributor," suggesting there are specific requirements or qualifications for participation in this contract vehicle, though the specific criteria are not detailed in this form.
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Text version
Contractor Name ___________________________________ Contract_________________________
23054i_Attachment 9 Page 1 of 5
Authorized Dealer/Distributor Information Contractor’s General
Commercial Qualifying Criteria for Dealers/Distributors:
Attach additional sheets, if necessary.
Dealer/Distributor (#1) Company Name:
Address:
FEDERAL ID #:
NYS VENDOR ID#:
(if receiving Payments)
Contract Administrator Name:
Title:
Telephone Number:
E-mail:
FAX:
Dealer/Distributor is Authorized to:
Take Orders Ship Direct Receive Payment
Shoemobile (Truck) Services Is Dealer/Distributor a
NYS certified Minority and Women-owned Business
Enterprise (M/WBE)
YES NO
Is Dealer/Distributor a NYS certified Service-Disabled
Veteran-Owned Business
(SDVOB)
Qualifying Criteria Applicable to this Dealer/Distributor:
(#2) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
Dealer/Distributor is Authorized to:
Take Orders Ship Direct Receive Payment
Shoemobile (Truck) Services Is Dealer/Distributor a
NYS certified Minority and
NYS certified Service-Disabled
23054i_Attachment 9 Page 2 of 5
Dealer/Distributor (#3) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
Dealer/Distributor is Authorized to:
Take Orders Ship Direct Receive Payment
Shoemobile (Truck) Services Is Dealer/Distributor a
NYS certified Minority and
NYS certified Service-Disabled
(#4) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
Dealer/Distributor is Authorized to:
Shoemobile (Truck) Services
NYS certified Minority and
NYS certified Service-Disabled
23054i_Attachment 9 Page 3 of 5
(#5) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
NYS certified Minority and
NYS certified Service-Disabled
(#6) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
NYS certified Minority and
NYS certified Service-Disabled
23054i_Attachment 9 Page 4 of 5
(#7) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
NYS certified Minority and
NYS certified Service-Disabled
(#8) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
NYS certified Minority and
NYS certified Service-Disabled
23054i_Attachment 9 Page 5 of 5
Dealer/Distributor (#9) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
NYS certified Minority and
NYS certified Service-Disabled
(#10) Company Name:
Address:
FEDERAL ID #:
Telephone Number:
E-mail:
FAX:
NYS certified Minority and
NYS certified Service-Disabled
File details come from the government source that posted it. Updated .