4006123361attachment13_contractor_reseller_information.docx
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This document is an Attachment 13 Contractor and Reseller Information form for a New York State Office of General Services (OGS) statewide contract (Group 40061) for Protective Outerwear, specifically covering Firefighting, Emergency/Rescue, and Safety equipment. The form is designed to provide comprehensive contact and administrative details for contractors and their authorized resellers, with specific emphasis on maintaining up-to-date information for contract management purposes.
The contract includes provisions for tracking Minority- and Women-owned Business Enterprise (MWBE) participation, with specific requirements for reporting reseller changes. The document provides templates for contractors to list their company information, contract administration contacts, sales and billing details, emergency contacts, and invoice entity information. Additionally, the form allows for documenting shoe mobile/truck services, brick-and-mortar store locations, and detailed reseller information, including certification status (such as NYS Certified Women Owned, NYS Certified Minority Owned, or SDVOB Small Business Enterprise). Resellers can be authorized to take orders, receive payments, and ship directly, with the form enabling precise tracking of their capabilities and potential restrictions.
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GROUP 40061 – Protective Outerwear (Firefighting, Emergency/Rescue, and Safety) (Statewide) Page 1 of 4
ATTACHMENT 13
CONTRACTOR and RESELLER INFORMATION (for ordering and contract administration purposes)
NOTE: Contractors MUST submit an updated form to OGS EVERY TIME a Reseller is added or removed. If a contract has Minority- and/or Women-owned Business Enterprise (MWBE) participation goals, in addition to this form, Contractors MUST submit to OGS a completed MWBE 100 form EVERY TIME they add or remove a Reseller that has been certified by NYS as an MWBE.
(The MWBE 100 form is available under the “Commodity & Service Contracts” section at: https://ogs.ny.gov/mwbe/forms).
If more space is needed than provided, please copy and paste additional tables / pages to this document.
CONTRACTOR INFORMATION
Company Business Name:
D/B/A – Doing Business As (if applicable):
Address:
Company Website:
Federal Tax ID #:
NYS Vendor ID #:
CONTRACT ADMINISTRATION
Contract Administrator Name:
Title:
Address (if different from above):
Email:
Phone:
Toll Free Phone:
SALES/BILLING (if different from above)
Contact Name:
Title:
Address:
Email:
Phone:
Toll Free Phone:
Business Hours (Specify M-F, Sat, Sun):
EMERGENCIES
Contact Name:
Title:
Address:
Email:
Phone:
Cell Phone:
INVOICING
Entity information that will appear on invoices, for orders placed directly with the Contractor, if different from Contractor/Company information above.
Invoicing Entity Company Name:
Federal Tax ID #:
NYS Vendor ID #:
Is payment made to the above Entity/Federal ID#?
Note: If yes, the invoicing entity NYS Vendor ID MUST be referenced on Purchase Orders ☐ Yes ☐ No
Shoe Mobile / Truck Information (if applicable):
SHOE-MOBILE / TRUCK (if offered by Contractor for Products under Lot 7 – Safety Shoes)
Contact Name:
Title:
Email:
Phone:
Cell Phone:
SHOE-MOBILE / TRUCK (if offered by Contractor for Products under Lot 7 – Safety Shoes)
Contact Name:
Title:
Email:
Phone:
Cell Phone:
SHOE-MOBILE / TRUCK (if offered by Contractor for Products under Lot 7 – Safety Shoes)
Contact Name:
Title:
Email:
Phone:
Cell Phone:
Brick and Mortar Store Information (if applicable):
BRICK and MORTAR STORE (if offered by Contractor for Products under Lot 7 – Safety Shoes)
Store Name:
Street Address:
City, Zip Code
Hours:
Contact Name:
Phone:
Cell Phone:
BRICK and MORTAR STORE (if offered by Contractor for Products under Lot 7 – Safety Shoes)
Store Name:
Street Address:
City, Zip Code
Hours:
Contact Name:
Phone:
Cell Phone:
BRICK and MORTAR STORE (if offered by Contractor for Products under Lot 7 – Safety Shoes)
Store Name:
Street Address:
City, Zip Code
Hours:
Contact Name:
Phone:
Cell Phone:
Resellers for the Contract are listed below. For an Authorized User to obtain MWBE or SDVOB credit, the applicable MWBE or SDVOB Reseller/Distributor/Dealer MUST be allowed to “Take Orders AND Receive Payment" and be entered into SFS with their own NYS Vendor ID #. An MWBE Reseller that is noted as a “Broker” in the “Restrictions Applicable to this Reseller” field has been identified as a Broker in the NYS Directory of Certified Firms located at https://ny.newnycontracts.com, and the Contractor and the Authorized User will receive only a 25% MWBE credit for its utilization.
RESELLER INFORMATION
Company Business Name:
| Is this Reseller a Brick-and-Mortar Store? |
| Choose an item. |
| Does this Reseller offer Shoe Mobiles? |
| Choose an item. |
| Address: |
Federal Tax ID #:
NYS Vendor ID #:
Contact Name:
Title:
Email:
Hours of Availability:
Phone:
Cell Phone:
MWBE and/or SDVOB Certification:
☐ NYS Certified Women Owned ☐ NYS Certified Minority Owned ☐ SDVOB
| SBE: |
| ☐ NYS Small Business Enterprise (self-identified) |
| Reseller is Authorized to: (check all that apply) |
| ☐ Take Orders AND Receive Payment ☐ Ship Direct |
Restrictions Applicable to this Reseller (if any):
RESELLER INFORMATION
Company Business Name:
| Is this Reseller a Brick-and-Mortar Store? |
| Choose an item. |
| Does this Reseller offer Shoe Mobiles? |
| Choose an item. |
| Address: |
Federal Tax ID #:
NYS Vendor ID #:
Contact Name:
Title:
Email:
Hours of Availability:
Phone:
Cell Phone:
MWBE and/or SDVOB Certification:
☐ NYS Certified Women Owned ☐ NYS Certified Minority Owned ☐ SDVOB
| SBE: |
| ☐ NYS Small Business Enterprise (self-identified) |
| Reseller is Authorized to: (check all that apply) |
| ☐ Take Orders AND Receive Payment ☐ Ship Direct |
Restrictions Applicable to this Reseller (if any):
RESELLER INFORMATION
Company Business Name:
| Is this Reseller a Brick-and-Mortar Store? |
| Choose an item. |
| Does this Reseller offer Shoe Mobiles? |
| Choose an item. |
| Address: |
Federal Tax ID #:
NYS Vendor ID #:
Contact Name:
Title:
Email:
Hours of Availability:
Phone:
Cell Phone:
MWBE and/or SDVOB Certification:
☐ NYS Certified Women Owned ☐ NYS Certified Minority Owned ☐ SDVOB
| SBE: |
| ☐ NYS Small Business Enterprise (self-identified) |
| Reseller is Authorized to: (check all that apply) |
| ☐ Take Orders AND Receive Payment ☐ Ship Direct |
Restrictions Applicable to this Reseller (if any):
RESELLER INFORMATION
Company Business Name:
| Is this Reseller a Brick-and-Mortar Store? |
| Choose an item. |
| Does this Reseller offer Shoe Mobiles? |
| Choose an item. |
| Address: |
Federal Tax ID #:
NYS Vendor ID #:
Contact Name:
Title:
Email:
Hours of Availability:
Phone:
Cell Phone:
MWBE and/or SDVOB Certification:
☐ NYS Certified Women Owned ☐ NYS Certified Minority Owned ☐ SDVOB
| SBE: |
| ☐ NYS Small Business Enterprise (self-identified) |
| Reseller is Authorized to: (check all that apply) |
| ☐ Take Orders AND Receive Payment ☐ Ship Direct |
Restrictions Applicable to this Reseller (if any):
23361 Attachment13_Contractor and Reseller Information
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