9-Vendor Information Form - 2024.docx
DOCX document 24 KB Posted
- Attached to
- Laboratory Testing - UG/AG Storage Tanks - COOP
- Solicitation number
- BC-BID-26-06
- Issued by
- Bergen County, New Jersey
About this file
This is a Vendor Information Form from the County of Bergen, New Jersey, Department of Administration and Finance, Division of the Treasurer. The form is designed to collect essential vendor registration information for entities seeking to do business with Bergen County. The document requests standard vendor identification details including company name, address, authorized official contact information, and communication preferences regarding purchase order delivery. The form also requires vendors to specify whether they prefer purchase orders to be emailed or submitted through alternative means, and includes a section for alternative remittance addresses if payment should be directed to a location different from the primary business address.
The form includes vendor business classification requirements, requiring companies to identify their IRS classification and special business status designations such as small business, minority-owned, women-owned, veteran-owned, or tax-exempt organization status. Vendors must select from multiple entity type options including sole proprietor, C-Corporation, S-Corporation, Partnership, Limited Liability Corporation (in various configurations), or Trust/Estate structures. The form concludes with a certification statement requiring an authorized representative to confirm the accuracy of all provided information through a printed name and signature. This vendor information form serves as a standard registration document for the County of Bergen's procurement process related to the Laboratory Testing for Underground and Above Ground Storage Tanks cooperative contract opportunity.
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Text version
COUNTY OF BERGEN DEPARTMENT OF ADMINISTRATION AND FINANCE
DIVISION OF THE TREASURER
One Bergen County Plaza• Suite 501 • Hackensack, N.J. 07601-7076
(201) 336-6550 • (201 336-6595
James J. Tedesco, Ill County Executive
Jon Rheinhardt
CFO
Melissa Howard Treasurer
* - Required field
VENDOR INFORMATION FORM
Vendor Information (as displayed on W-9 form):
Company Name*:
Address*:
City*:
State*:
Zip Code*:
Name of Authorized Official*:
Phone Number*:
Email Address*:
| Would you prefer that PO's to be emailed to the email address provided? * | |
| □Yes | □No |
Remittance Address: (if different than information above) Pay-To-Name:
Pay-To-Address:
Pay-To-City:
Pay-To-State:
Pay-To-Zip:
Pay-to Attn:
Payment Email:
Business Classification:
| Is your company a: * |
| IRS Classification: * |
| □ Small Business |
| □ Individual/ Sole proprietor |
| □ Minority Owned |
| □ C-Corp |
| □ Women Owned |
| □ S-Corp |
| □ Veteran Owned |
| □ Partnership |
| □ Other: |
| □ Trust/Estate |
| □ Not Applicable |
| □ Limited Liability Corp - Corporation |
□ Limited Liability Corp - S Corporation
□ Limited Liability Corp - Partnership
□ Tax-Exempt Organization
I certify that the information provided on this form is true and accurate to the best of my knowledge.
Print Name: Signature:
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