Sample New Vendor Form – Procurement

Description

City of Everett, Massachusetts Finance Department 484 Broadway Everett, MA 02149 Tel: (617) 394-2210 Fax: (617) 394-2453 VENDOR INFORMATION REQUEST FORM The information requested on this form is designed to help the City identify the types of work your company may be qualified to perform and to flag areas that may require further discussion prior to awarding a purchase order or contract. The intent of this form is to expedite the purchasing process by identifying potential issues early in the process. You are not restricted to the below space and pages, please add pages if necessary. Please contact the Finance Department with any questions. (Answering “No” to any of the following questions may not disqualify you from doing business with the City. Incomplete or blank boxes will result in unnecessary delays and the form may be rejected. Please be as thorough as possible. ) List the City Department requesting the Service or Goods: Business Information 1. Business Name 2. Remit Address 3. Website Federal Tax ID #: 4. Payee Identification (List only one) Social Security #: C 5. Type of Organizational Structure Corporation Partnership Sole Proprietor 6. Parent Company 7. Type of Organization (Please check all that apply) Service Consulting Construction 8. Describe the nature of products/services. Supplies / Materials Other: Type Non-Profit S LLC Yes No 9. Are your services or goods you are providing on the State bid list? 11. Does your insurance coverage meet the City's requirement? General Commercial Liability $1,000,000 per occurrence Minimum Automobile Liability $1,000,000 per accident Minimum Employer's Liability $1,000,000 per accident Minimum Workers’ Compensation Statutory Limits Minimum 12. Do you or your company have a Drug Screening Program? 13. Do you or your company perform employee background checks? 14. Do you or your company adhere to a code of ethics? 15. Have you or your company performed work under a U.S. Government funded program? 16. Federal Contracting Suspension/Debarment: Is your company or any of its principals under debarment, declared ineligible, or voluntarily excluded from covered transactions by any U.S. Government department or agency? 17. Are you aware of the Federal and State Prevailing Wage laws? 18. No principal, officer, or manager of the company has a direct family relationshionship with any of the City's elected officials or employees? 19.