Attachment_C_-_Vendor_Information_Request_Form.pdf
PDF 80 KB Posted
- Attached to
- TRWRP 93 Motor Control Center Replacement
- Solicitation number
- RFB-TH-0120
- Issued by
- Los Angeles County, California
About this file
This Vendor Information Request Form is used by West Basin Municipal Water District to collect comprehensive vendor registration and certification data for the TRWRP 93 Motor Control Center Replacement project. The form requires vendors to submit complete company information including legal name, address, contact details, and vendor number. Vendors must provide documentation of signature authority for contract execution, identify authorized representatives to receive executed agreements, and disclose certification status as Small Business Enterprises (SBEs) or Local Business Enterprises (LBEs) with supporting documentation. The form also requests accounts receivable and remittance information, payment terms acceptance (Net 30 days), W-9 receipt confirmation, and compliance verification with the Build America, Buy America (BABA) Act requiring 65 percent domestically sourced product components. The form is dated January 22, 2026, and includes authorization language permitting West Basin to verify submitted information.
The Vendor Information Request Form establishes West Basin's administrative procedures for vendor qualification and contract administration. Vendors must disclose all relevant business licensing, certification numbers, and public agency certifications, along with organizational tenure at listed addresses. The form requires vendors to authorize West Basin verification of provided information through signature, ensuring accountability and accuracy in the vendor registration process. By completing this form, vendors establish the foundational documentation required to proceed with bid submission and potential contract award for the motor control center replacement project, which mandates strict compliance with prevailing wage requirements, California contractor licensing, and comprehensive insurance coverage specifications.
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Text version
VENDOR INFORMATION REQUEST - West Basin Municipal Water District
Yes No
Yes No
Yes No
Entered By: Date: Yes No W-9 Received: Yes No
Email:
Title:
Address 2 (suite, unit, etc.):
Vendor Number:
Verified
SBE & LBE:
FOR PURCHASING ONLY
Email:
List the representative(s) from your organization that would like to receive a copy of the executed agreement:
Title: Print Name:
Print Name:
Email:
COMPANY INFORMATION
Complete Legal Name:
Address 1: Contact Phone:
Which Public Agency are you Certified With?
Certification Number:
Are you a Certified Small Business Enterprise (SBE)? If yes, Small Business certification must be submitted.
ACCOUNTS RECEIVABLE (remittance name and address)
City/State/Zip:
Contact Fax:
Remittance name: Contact Name:
Are you a Local Business Enterprise (LBE)?
If yes, please provide a copy of your business license.
Business License Number:
Address - Same as above
Address 1: Contact Phone:
ADDITIONAL INFORMATION
CONTRACTS/AGREEMENTS INFORMATION
Payment Discounts:
(West Basin terms: Net 30) Contact Email:
List the representative(s) from your organization that will be signing the agreement and attach proof of signature authority. Documentation should state that the representative has the authority to execute contracts—examples of proof: Articles of Incorporation, corporate resolution, written consent, etc.
Title: Print Name:
Title: Print Name:
Email:
Print Name:
Length of time at this address? Contact Email:
By signing, you authorize West Basin to verify the information stated on this form. Signature:
If applicable, do your company's products comply with the Build America, Buy America (BABA) Act?
(Product components are 65% domestically sourced.)
Address 2: Contact Fax:
City/State/Zip:
Title:
1-22-2026
| Complete Legal Name: |
| Length of time at this address: |
| Business License Number: |
| Remittance name: |
| Entered By: |
| Title: |
| Certification Number: |
| Which Public Agency are you Certified With: |
| Address 1: |
| Address 2: |
| Contact Fax: |
| Contact Phone: |
| City/State/Zip: |
| Contact Email: |
| Contact Name: |
| Print Name: |
| Email: |
| Vendor Number: |
| Payment Discounts: [NET 30 Days] |
| Contact Fax 2: |
| Address 3: |
| Address 4: |
| Contact Phone 2: |
| Contact Email 2: |
| City/State/Zip Code: |
| Title 1: |
| Title 2: |
| Title 3: |
| Title 4: |
| Print Name 2: |
| Print Name 3: |
| Print Name 4: |
| Email 2: |
| Email 3: |
| Email 4: |
| Print Name 1: |
| Date1_af_date: |
| Group5: Off |
| Check Box8: Off |
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