Exhibit C - Vendor Contact Information Sheet.pdf

Page 1 of 2 VCIS_1-26A

Colorado Department of Early Childhood Vendor Contact Information Sheet

Question or Information Needed: Answer:

Legal Name of Vendor as it should appear on the

Contract/Purchase Order including any doing business as

(dba):

Street Address including City, State and Zip Code:

Mailing Address including City, State and Zip Code (if different from Street Address):

County Agency is in:

Federal Entity Identification Number (FEIN) or Tax ID

Number (TIN):

State of Incorporation:

Secretary of State Identification/Document Number:

Fiscal Year End Date (Month and Day – format MM/DD):

All Vendors must have a SAM.gov Unique Entity Identification

(UEI) number (except individuals). SAM UEI number:

Are you a new vendor working with CDEC? ☐ Yes ☐ No

Does your Agency hire any current or former State

Employees to work on this project?

If yes, did they end employment with the State within the last 6 months?

Does your agency have a Federally Negotiated or State

Negotiated indirect Rate?

If yes, please send a copy of the approval letter with this form.

What type of Entity is your Agency? ☐ Individual

☐ Professional Corporation (PC)

☐ Sole Proprietor

☐ Not-for-Profit Corporation

☐ Limited Liability Company (LLC)

☐ Joint Venture

☐ For-Profit

☐ Limited Liability Partnership (LLP)

☐ Government

Question or Information Needed: Answer:

Primary Contact to Receive ALL Correspondence’s Name:

Primary Contact’s Title:

Primary Contact’s Email Address:

Primary Contact’s Phone Number:

Financial Contact’s Name:

Financial Contact’s Title:

Financial Contact’s Email Address:

Page 2 of 2 VCIS_1-26A

Question or Information Needed: Answer:

Financial Contact’s Phone Number:

Invoice Contact’s Name:

Invoice Contact’s Title:

Invoice Contact’s Email Address:

Invoice Contact’s Phone Number:

Individual Signing the Contract’s Name:

Individual Signing the Contract’s Title:

Individual Signing the Contract’s Email Address:

Individual Signing the Contract’s Phone Number:

Please list any special instructions for your agency to make the preliminary approval and DocuSign process run smoothly.

Examples:

• Please send request for preliminary approval to Primary Contact only.

• Someone needs to approve the document before it goes to the signer such as an attorney or program manager;

• Enter the internal routing number in the note in DocuSign for the Individual Signing the Contract.

Specific Notes/Requests:

Additional Contact’s Name:

Additional Contact’s Title:

Additional Contact’s Email Address:

Additional Contact’s Phone Number:

What does this Additional Contact need to do (check all that apply)?

☐ Email - Receive the document for preliminary approval

☐ DocuSign - Receive Copy Prior to Signer

☐ DocuSign - Approve Prior to Signer

☐ DocuSign - Sign Prior to Signer

☐ DocuSign - Sign after Signer

☐ DocuSign - Receive Copy upon execution

Is your agency set up for Electronic Fund Transfer (EFT) with the State of Colorado? ☐ Yes ☐ No

If yes, please list the last 4 digits of the account number payments should be sent to:

How long does your agency and/or board need to complete a preliminary review of the contract?

How long does your agency and/or board need to sign the contract in DocuSign?

Date This Form Was Completed: