Vendor-Contractor Application 2023.pdf

Purchasing Department 309 N. Washington Square Suite 202, Lansing MI 48933

PHONE: 517-483-1785

FAX: 517-483-5289

EMAIL: B-OPS-Purchasing@star.lcc.edu

CONTRACTOR APPLICATION

INSTRUCTIONS: Please provide all information (typed or printed) as requested in the spaces provided and return to the address listed above via secured email, mail or fax. The IRS requires that you provide information that will allow us to complete 1099 reporting. To ensure payment from the College, please submit a current W-9 along with your completed application.

General Information

Name of Company:

Website: General Email:

Federal ID:

Address: City: State: Zip:

Order to Address: City: State: Zip:

RFQ Address: City: State: Zip:

Remit to Address: City: State: Zip:

Order Contact:

Phone: Toll Free Phone: Fax:

Business Detail

Type of Business (check all the apply) Type of Organization (check all that apply)

Wholesaler Manufacturer Dealer Broker Corporation Non-Profit Sole Proprietor

Retailer General Contractor Sub-Contractor Partenership LLC PSC

Other; specify: Other; specify:

Business located within LCC District? Yes No Date Incorporated: State:

Business History and References Date Established:

Number of Employees:

References (3) (use additional attachment if necessary)

1.

2.

3.

Diversity Type

Diverse businesses must be at least 51% owned and controlled by one or more individuals who are represented in the categories selected. Include a copy of your certificate(s) with this application.

Please check all that apply:

Majority (non-diverse) Disabled

Minority; Ethnicity (please list one or more) Small Business

Women Owned; Ethnicity (please list one or more)

Conflict of Interest Policy

Does any officer, Director, Owner or Partner in this company have a relationship with Lansing Community College? Yes No The types of relationships include:

1. A spouse/ partner or minor child is employed with Lansing Community College

2. A financial relationship with a Lansing Community College employee.

3. A personal relationship with a Lansing Community College employee.

If yes, please identify this person and define that relationship:

Contractor Application (Signature Required)

The undersigned certifies that the information contained herein is current and correct.

Authorized Signature: Printed Name:

Title: Phone: Fax:

Product/ Service Categories

Please place a checkmark (√) by the appropriate code and provide a detailed description of the commodities and/or services offered.

If the complete NAICS Code is known please include this number in the description area. Website URL address for NAICS is:

http://www.census.gov/epcd/www/naics.html

NAICS CODE DESCRIPTION

11 – Agriculture, Forestry, Fishing and Hunting

21 – Mining

22 – Utilities

23 – Construction

31-33 – Manufacturing

42 – Wholesale Trade

44-45 – Retail Trade

48-49 Transportation and Warehousing

51 – Information

52 – Finance and Insurance

53 – Real Estate and Rental and Leasing

54 – Professional, Scientific and Technical Services

55 – Management of Companies and Enterprises

56 – Administrative & Support, Waste Management & Remediation Services

61 – Educational Services

62 – Health Care and Social Assistance

71 – Arts, Entertainment and Recreation

72 – Accommodation and Foodservices

81 – Other Services (except Public Administration)

92 – Public Administration

99 – Unclassified Establishments

Lansing Community College is committed to providing equal employment opportunities and equal education for all persons regardless of race, color, sex, age, religion, national origin, creed, ancestry, height, weight, sexual orientation, gender identity, gender expression, disability, familial status, marital status, military status, veteran’s status, or other status as protected by law, or genetic information that is unrelated to the person’s ability to perform the duties of a particular job or position or that is unrelated to the person’s ability to participate in educational programs, courses, services or activities offered by the college.

The following individuals have been designated to handle inquiries regarding the nondiscrimination policies: Equal Opportunity Officer, Washington Court Place, 309

N. Washington Square Lansing, MI 48933, 517-483-1730; Employee Coordinator 504/ADA, Administration Building, 610 N. Capitol Ave. Lansing, MI 48933, 517-

483-1875; Student Coordinator 504/ADA, Gannon Building, 411 N. Grand Ave. Lansing, MI 48933, 517-483-1885; Lori Willett, Human Resource Manager/Title IX

Coordinator, Administration Building, 610 N. Capitol Ave. Lansing, MI 48933, 517-483-1870; Christine Thompson, Student Title IX Coordinator, Gannon Building, 411 N. Grand Ave. Lansing, MI 48933, 517-483-1261.