Vendor_Information_Request_Form_-_fillable.pdf

PDF 67 KB Posted

Attached to
Supply of Reverse Osmosis (RO) Membranes for the Juanita Millender-McDonald Carson Regional Water Recycling Plant
Solicitation number
IFQ-TH-0119
Issued by
Los Angeles County, California

About this file

Written by GovTribe AI ·

This is a Vendor Information Request Form used by West Basin Municipal Water District in California to collect comprehensive vendor data for potential contractors. The form gathers essential company information including legal business name, addresses, contact details, and vendor identification numbers. The document requests documentation of certifications, specifically Small Business Enterprise (SBE) and Local Business Enterprise (LBE) status, along with proof of signature authority from representatives authorized to execute contracts on behalf of the vendor. The form also collects information about payment terms, with West Basin operating on a Net 30 payment schedule, and requests representatives' names and contact information for receiving executed agreements.

Additional requirements outlined in the form include submission of a completed W-9 form and verification of business licensing where applicable. The form specifically addresses compliance with the Build America, Buy America (BABA) Act, requiring confirmation that product components are 65% domestically sourced if applicable to the vendor's offerings. By signing the form, vendors authorize West Basin to verify the information provided. This form is directly associated with West Basin's invitation for qualified bidders to submit quotations for the supply of Reverse Osmosis (RO) Membranes for the Juanita Millender-McDonald Carson Regional Water Recycling Plant located in California.

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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:
Yes:
No:
Same:
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:
Yes 3:
No 3:
Yes 4:
No 4:
Print Name 1:
Yes 1:
No 1:
Yes 2:
No 2:
Date1_af_date:

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