Vendor_Information_Request_Form_.pdf

77 KB Posted

Attached to
Grant Writing Assistance Services
Solicitation number
RFP-TH-0137
Issued by
Los Angeles County, California

About this file

Written by GovTribe AI ·

This is a Vendor Information Request Form for West Basin Municipal Water District in California, used to collect vendor registration and compliance documentation from companies seeking to conduct business with the agency. The form captures essential company information including legal name, business addresses, contact details, and vendor identification numbers. It requests documentation of signature authority for contract execution, such as Articles of Incorporation or corporate resolutions, and identifies designated representatives who will receive executed agreements and authorize contract signatures. The form also requires vendors to indicate their willingness to allow West Basin to verify the submitted information and authorizes the agency to validate all stated details.

The form addresses vendor certifications and compliance requirements, including Small Business Enterprise (SBE) and Local Business Enterprise (LBE) certifications, along with associated documentation such as business licenses and certification numbers from relevant public agencies. It specifies West Basin's standard payment terms as Net 30 days and requests information regarding payment discounts. Additionally, the form inquires whether vendors' products comply with the Build America, Buy America (BABA) Act, requiring 65 percent domestic sourcing of product components. The form includes multiple fields to accommodate various contact representatives, remittance addresses, and communication methods, providing West Basin with comprehensive vendor information necessary for vendor management, payment processing, and contract administration purposes.

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VENDOR INFORMATION REQUEST - West Basin Municipal Water District

Yes No

Yes No

Yes No

Entered By: Date: Yes No W-9 Received: Yes No

Email:

Title:

Address 2 (suite, unit, etc.):

Vendor Number:

Verified

SBE & LBE:

FOR PURCHASING ONLY

Email:

List the representative(s) from your organization that would like to receive a copy of the executed agreement:

Title: Print Name:

Print Name:

Email:

COMPANY INFORMATION

Complete Legal Name:

Address 1: Contact Phone:

Which Public Agency are you Certified With?

Certification Number:

Are you a Certified Small Business Enterprise (SBE)? If yes, Small Business certification must be submitted.

ACCOUNTS RECEIVABLE (remittance name and address)

City/State/Zip:

Contact Fax:

Remittance name: Contact Name:

Are you a Local Business Enterprise (LBE)?

If yes, please provide a copy of your business license.

Business License Number:

Address - Same as above

Address 1: Contact Phone:

ADDITIONAL INFORMATION

CONTRACTS/AGREEMENTS INFORMATION

Payment Discounts:

(West Basin terms: Net 30) Contact Email:

List the representative(s) from your organization that will be signing the agreement and attach proof of signature authority. Documentation should state that the representative has the authority to execute contracts—examples of proof: Articles of Incorporation, corporate resolution, written consent, etc.

Title: Print Name:

Title: Print Name:

Email:

Print Name:

Length of time at this address? Contact Email:

By signing, you authorize West Basin to verify the information stated on this form. Signature:

If applicable, do your company's products comply with the Build America, Buy America (BABA) Act?

(Product components are 65% domestically sourced.)

Address 2: Contact Fax:

City/State/Zip:

Title:

1-22-2026

Complete Legal Name:
Length of time at this address:
Business License Number:
Remittance name:
Entered By:
Title:
Certification Number:
Which Public Agency are you Certified With:
Address 1:
Address 2:
Contact Fax:
Contact Phone:
City/State/Zip:
Contact Email:
Contact Name:
Print Name:
Email:
Vendor Number:
Payment Discounts: [NET 30 Days]
Contact Fax 2:
Address 3:
Address 4:
Contact Phone 2:
Contact Email 2:
City/State/Zip Code:
Title 1:
Title 2:
Title 3:
Title 4:
Print Name 2:
Print Name 3:
Print Name 4:
Email 2:
Email 3:
Email 4:
Print Name 1:
Date1_af_date:
Check Box8: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box9: Off
Check Box10: Off
Check Box11: Off
Check Box12: Off
Check Box13: Off
Check Box14: Off

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