CITY OF
VENDOR'S APPLICATION
LOCAL & MWBE
PARTICIPATION PROGRAM
Please answer the following questions regarding
your business. From the information given, we will add to the City's Minority
Program data base for bidding purposes. It is preferred that you type or print
your responses as to avoid possible errors in transcription. Mail application to: City of
Business
name:
Address:
City/State/Zip:
Mailing address(if
different):
Telephone number:
( ) -
Fax Machine
number: ( ) -
Email Address: Web
Address:
FEIN #:
Business
Classification: Corporation Partnership Sole Proprietorship
Are you a City of
If yes, please
state what Department
Do you have an
Affirmative Action Program?
Do you have a Drug
Free Work Place Program?
Specify Local/MWBE Type & Percentage of Controlling Ownership (51% or more):
□
Asian Indian % □ Black % □ Asian Pacific %
□
Native American % □ Small Business % □ Women Owned %
□
Hispanic % □ Small Disadvantage %
□ Local %
Service/Commodity:
I certify that the information supplied herein (including all papers attached) is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principle or officer, so far as it is known, is now debarred or otherwise declared ineligible by any agency of the City from bidding for furnishing materials, supplies or services to the City or any other agency thereof.
Signature of person authorized to
sign this application:
Name and Title of Person
Signing:
Date: