Vendor Name:

(Must be Exactly as shown on Social Security card or federal employer identification)

DBA (doing business as): 

(If Applicable)

Address to which purchase orders should be mailed:
 

Street or PO box:

City:                 

State:                Select a State Not Applicable Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:           

Federal Tax ID Number:

Telephone Number: 
 

Fax number:          

Remittance Address (If different from above):
 

Street or PO box:

City:                 

State:                Select a State Not Applicable Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:           

Email Address:     

The following goods and/and or services can be supplied under this request.  You can select up to four categories:

Select a Category Advertising Accounting Computer Networking

Please check all applicable categories:

               

	Historically Underutilized Business (HUB)
	Disadvantaged Business Enterprise (DBE)
	Small Disadvantaged Business Enterprise (SDBE)
	Certified Minority Business
The above Minority Business information is requested strictly for statistical purposes and will not influence the amount of expenditures the City will make with any given company.