REQUIRED_FORMS_-_AAs_-_FOR_INFORMALS.pdf

Purchasing Division 100 N. Garfield, Room S348 Pasadena, CA 91101 Phone (626) 744-6755 https://www.cityofpasadena.net/finance/doing-business-with-the-city/

Vendor Questionnaire (Form AA-1)

Affidavit of Equal Opportunity Employment & Non-segregation

By submitting this form you are declaring under penalty of perjury under the laws of the State of California and the laws of the

United States that the information is true and correct. Furthermore, you are certifying that your firm will adhere to equal opportunity employment practices to assure that applicants and employees are not discriminated against because of their race, religion, color, national origin, ancestry, disability, sex or age. And, your firm does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform their services at any location, under its control, where segregated facilities are maintained.

Company Name:

Address:

City, State, Zip:

Contact Person:

Phone:

E-mail Address:

DBA (if applicable):

Remit Address (if different):

City, State, Zip:

Please state clearly and concisely the type(s) of goods and services your company would provide on this contract

The following section is OPTIONAL and is for statistical reporting purposes only. Ownership (please check all that apply):

☐African American

☐Asian

☐Armenian

☐Hispanic

☐Native

American

☐Disabled

☐Female

Purchasing Division

100 N. Garfield, Room S348

Pasadena, CA 91101

Phone (626) 744-6755

Licenses and Certifications

Review the solicitation document to identify the required licenses or certifications, and list them on this form. This form is for quick reference only.

Company Name: __________________________________________________________

Project:__________________________________________________________________

Address: _______________________________________________________________

City, State, Zip: _______________________________________________________________

Phone: _____________________________

Email Address: _________________________________________________________

Agency, and Description Number

City of Pasadena (Pasadena Business License)

State of California, Department of Industrial Relations (Required For all Public Works: Pursuant to Division 2, Part 7, Chapter 1)

State of California, Department of General Services (Small and Micro Business Certification)

License/Certification Name

Issuing Organization Issue Date Status License or Certification Number