Vendor_Information_Request_Form_.pdf

PDF 80 KB Posted

Attached to
Supply and Delivery of Three (3) Electric Vehicle Chargers
Solicitation number
IFQ-TH-0122
Issued by
Los Angeles County, California

About this file

Written by GovTribe AI ·

This is a Vendor Information Request Form used by the West Basin Municipal Water District in California for the Supply and Delivery of Three (3) Electric Vehicle Chargers. The form serves as a vendor registration and qualification document that collects comprehensive company information, certifications, and authorized representatives from interested bidders. The request captures essential business details including legal company name, contact information, business addresses, and identification of personnel authorized to sign agreements on behalf of the vendor.

The form requires vendors to provide documentation of Small Business Enterprise (SBE) and Local Business Enterprise (LBE) certifications if applicable, along with business license information and the certifying public agency details. Payment terms are established at Net 30 days, and vendors must confirm compliance with the Build America, Buy America (BABA) Act requiring 65% domestically sourced product components. The form also mandates that vendors provide proof of signature authority for their designated contract representatives through supporting documentation such as Articles of Incorporation or corporate resolutions. All submitted information is subject to verification by West Basin Municipal Water District, and the form was dated January 22, 2026.

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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:
Group5: Off
Check Box8: Off

File details come from the government source that posted it. Updated .