Exhibit D - Vendor Contact Information Sheet.pdf

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Colorado Department of Early Childhood Vendor Contact Information Sheet

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

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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:

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:

The Colorado Department of Early Childhood Collects signatures via DocuSign. Please list below any individuals that need to be included in the DocuSign process (examples:

Director’s Assistant, Attorney, etc.)

Additional Contact’s Name:

Additional Contact’s Title:

Additional Contact’s Email Address:

Additional Contact’s Phone Number:

What does this person need to do? ☐ Sign before Individual Signing

Contract and receive a copy upon execution

☐ Sign after Individual Signing

Contract and receive a copy upon execution

☐ Receive Copy Prior to Signer and upon execution

☐ Approve Prior to Signer and receive a copy upon execution

☐ Receive Copy upon execution only

Are there any specific instructions for emails requesting preliminary approval or order of DocuSign for signature (examples: enter the internal routing number in the note in DocuSign for the Individual Signing the Contract; Please send in DocuSign in the following order; Please send for preliminary approval to Primary Contact only; etc.)?

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

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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: