9-Vendor Information Form - 2024.docx
DOCX document 24 KB Posted
- Attached to
- Environmental: Sampling and Consulting Services
- Solicitation number
- BC-RFP-26-004
- 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, required for participation in the Environmental: Sampling and Consulting Services contract opportunity (BC-RFP-26-004). The form collects essential vendor registration data including company name, authorized contact information, and business classification details. The related contract opportunity is for environmental sampling and consulting services with a 24-month initial term commencing upon award, followed by three optional 12-month renewal periods, providing potential contract duration of up to 60 months.
The Vendor Information Form requires vendors to provide standard business identification information, including IRS classification type (such as C-Corporation, S-Corporation, LLC, sole proprietor, or partnership), and to identify if the company qualifies as a small business, minority-owned, women-owned, or veteran-owned enterprise. Vendors must also specify whether purchase orders should be sent to the email address provided and furnish separate remittance and payment information if different from the primary vendor address. The form requires certification that all provided information is accurate and must be signed by an authorized representative. No pricing, set-asides, or specific funding information is detailed in this registration document.
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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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