Name of Business*

Business Address*

City*

State*

Zip Code*

Address to which bid request and other information is to be mailed*

Invoice and payment address

Prompt Payment Discounts

Contact Information

Name*

Title

Telephone (excluding dashes; ex. 9544571234)

Fax Number (excluding dashes; ex. 9544571234)

Email Address*

Federal Tax I.D. Number or SSN of an individual*

Type of Business / Goods / Service. Please be specific. Include all:

Number of years in business with present business name providing the good/services.

Number of years in business with other business name providing the good/services.

The undersigned hereby certifies that the above and foregoing information is a complete, true, and correct statement of the facts.

Authorized Signature*

Print Name*

Title

Date