Form 11 Vendor Information Form 20260515.pdf
PDF 851 KB Posted
- Attached to
- ADA MENTOR PROTEGE PILOT PROGRAM
- Solicitation number
- B2727161
- Issued by
- Pennsylvania
About this file
This Form 11 Vendor Information Form is associated with the ADA Mentor Protege Pilot Program administered by the Commonwealth of Pennsylvania. The program represents a procurement opportunity with an engineer's estimate ranging from $1,000,000.00 to $2,000,000.00, designed to support mentor-protege partnerships under Americans with Disabilities Act (ADA) initiatives. The form serves as the primary documentation for vendor qualification and information submission during the procurement process.
The bid processing fee for this opportunity is $200.00. As a vendor information form, this document captures critical details about participating firms, including their qualifications, experience, organizational structure, and commitment to the mentor-protege pilot program objectives. The form facilitates the evaluation of vendor suitability and capacity to execute the contracted services or deliverables outlined in the associated procurement solicitation.
View the file
Other files
Show all 15
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Rev. 5/15/26 Page 1 of 2
Vendor Information Form City of Philadelphia Procurement Department 1401 JFK Blvd. MSB Room 170B, Philadelphia, PA 19102-1685 Email: pvcoop@phila.gov
Instructions
New Vendors: For vendors registering with the City for the first time, only the Current Information column needs to be completed. The Organization Information section must match a current, signed W-9 (within the past 6 months) submitted along with this form.
Existing Vendors: For vendors already doing business with the City, the Former Information column should reflect the information that was previously on file with the City. All changes to information previously submitted should be reflected in the corresponding field(s) under the Current Information column. Any updates to the Organization Information section must match a current, signed W-9 (within the past 6 months) submitted along with this form.
Questions, completed forms, and accompanying documentation can be submitted to pvcoop@phila.gov.
Former Information Current Information
Organization Information
Name of Entity W-9 line 1
Federal Tax ID (EIN) W-9 part I
Doing Business As (DBA) W-9 line 2
(if applicable)
Disregarded Entity Name W-9 line 2
(if applicable)
Disregarded Entity EIN (if applicable and it has its own, distinct EIN)
Are you registered with the
City of Philadelphia as a Local
Business Entity (LBE)?
Yes No Yes No
Are you registered with the
U.S. Small Business
Administration?
• Small Business
Enterprise (SBE)
• Small Disadvantaged
Business (SDB)
• 8(a) Business
Development Program
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Are you registered on
PHLContracts?
Yes No Yes No mailto:pvcoop@phila.gov mailto:pvcoop@phila.gov
Rev. 5/15/26 Page 2 of 2
Former Information Current Information
Corporate Address
Address Line 1
Address Line 2
City/State/Zip code
Mailing Address (name and address for correspondence)
Business Name
Address Line 1
Address Line 2
City/State/Zip code
Payment Address (name and address for payments)
Business Name
Address Line 1
Address Line 2
City/State/Zip code
Primary Vendor Contact
Name
Phone Number
Email Address
Secondary Vendor Contact
Name
Phone Number
Email Address
Website Address
By submitting this form you verify that all information submitted to the City of Philadelphia is true and correct and you are notified that submission of false information by you is subject to the penalties of 18 Pa.C.S Section 4904 relating to unsworn falsification to authorities.
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Check Box8: Off |
| Check Box9: Off |
| Check Box10: Off |
| Former Name of Entity: |
| Former Federal Tax ID (EIN): |
| Former Doing Business As (DBA) Name: |
| Former Disregarded Entity Name: |
| Former Disregarded Entity EIN: |
| Former Corporate Address Line 1: |
| Former Corporate Address Line 2: |
| Former Corporate City/State/Zip Code: |
| Former Mailing Address Business Name: |
| Former Mailing Address Line 1: |
| Former Mailing Address Line 2: |
| Former Mailing Address City/State/Zip Code: |
| Former Payment Address Business Name: |
| Former Payment Address Line 1: |
| Former Payment Address Line 2: |
| Former Payment Address City/State/Zip Code: |
| Former Primary Contact Name: |
| Former Primary Contact Phone Number: |
| Former Primary Contact Email Address: |
| Former Secondary Contact Phone Number: |
| Former Secondary Contact Name: |
| Former Secondary Contact Email Address: |
| Former Website Address: |
| Current Name of Entity: |
| Current Federal Tax ID (EIN): |
| Current Doing Business As (DBA) Name: |
| Current Disregarded Entity Name: |
| Current Disregarded Entity EIN: |
| Current Corporate Address Line 1: |
| Current Corporate Address Line 2: |
| Current Corporate City/State/Zip Code: |
| Current Mailing Address Business Name: |
| Current Mailing Address Line 1: |
| Current Mailing Address Line 2: |
| Current Mailing Address City/State/Zip Code: |
| Current Payment Address Business Name: |
| Current Payment Address Line 1: |
| Current Payment Address Line 2: |
| Current Payment Address City/State/Zip Code: |
| Current Primary Contact Name: |
| Current Primary Contact Phone Number: |
| Current Primary Contact Email Address: |
| Current Secondary Contact Name: |
| Current Secondary Contact Email Address: |
| Current Secondary Contact Phone Number: |
| Current Website Address: |
File details come from the government source that posted it. Updated .