NORTH ARKANSAS COLLEGE BIDDERS MAILING LIST APPLICATION
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1 NORTH ARKANSAS COLLEGE BIDDERS MAILING LIST APPLICATION RETURN TO: NORTH ARKANSAS COLLEGE TELEPHONE NUMBER: PURCHASING DEPARTMENT 1515 PIONEER DRIVE FAX NUMBER: HARRISON AR FOR OFFICE USE ONLY DATE ENTERED: COMPLETE SECTIONS A, B AND C IN THEIR ENTIRETY. SECTION A 1. MAIL BID INVITATIONS TO: 2. NAME OF BUSINESS: STREET OR P. O. BOX: CITY: STATE: ZIP CODE: ATTN: TELEPHONE NUMBER: FAX NUMBER: 3. FEDERAL EMPLOYER I.D. NUMBER: (SOCIAL SECURITY NUMBER IF APPLICANT IS AN INDIVIDUAL) 4. HOME OFFICE ADDRESS: NOTICE BIDDER IS RESPONSIBLE FOR UPDATING THE ABOVE INFORMATION. BIDS RETURNED TO NORTH ARKANSAS COLLEGE FOR INCORRECT ADDRESS WILL CAUSE BIDDER TO BE REMOVED FROM BIDDERS MAILING LIST.
2 5. TYPE OF ORGANIZATION INDIVIDUAL PARTNERSHIP CORPORATION DATE OF INCORPORATION WHICH STATE 6. TYPE OF BUSINESS MANUFACTURER OF PRODUCTS FACTORY REPRESENTATIVE SERVICE ESTABLISHMENT INSURANCE AGENT OR COMPANY JOBBER WHOLESALER RETAILER 7. OWNERSHIP OF BUSINESS WHITE, NOT HISPANIC HISPANIC AMERICAN INDIAN OR ALASKAN NATIVE ASIAN OR PACIFIC ISLANDER 8. DO YOU QUALIFY AS A SMALL BUSINESS? 9. HOW LONG IN PRESENT BUSINESS? IF TIME PERIOD DOES NOT COINCIDE WITH DATE OF INCORPORATION (RESPONSE IN #5 ABOVE), ATTACH SEPARATE SHEET WITH EXPLANATION.
3 10. (A) HAVE YOU AND/OR ANY INDIVIDUALS SERVING AS OFFICERS, KEY EMPLOYEES, PRINCIPALS, OR PARTNERS IN YOUR CURRENT BUSINESS, OR YOU AND/OR THE ABOVE MENTIONED INDIVIDUALS EMPLOYED IN ANY PREVIOUS BUSINESS ENTITIES, BEEN SUSPENDED OR DEBARRED FROM ANY STATE, CITY, COUNTY, FEDERAL OR OTHER GOVERNMENTAL ENTITY? (B) HAS ANYONE FILED A COMPLAINT AGAINST YOU OR OTHERS LISTED IN (A) ABOVE OR YOUR MERCHANDISE OR SERVICE? (C) HAS A PERFORMANCE PENALTY EVER BEEN ASSESSED AGAINST YOU OR OTHERS LISTED IN (A) ABOVE? IF YOUR RESPONSE WAS YES TO #10 (A), (B), OR (C) ATTACH A SEPARATE SHEET WITH EXPLANATION. PERSON AUTHORIZED TO SIGN BIDS. THIS LIST MUST BE MANUALLY SIGNED IN INK AND KEPT CURRENT. SIGNATURE NAME TITLE TELEPHONE NUMBER SIGNATURE NAME TITLE TELEPHONE NUMBER SECTION B 1. NET WORTH OF BUSINESS: $ AS OF (DATE). 2. DUN AND BRADSTREET FINANCIAL RATING OF BUSINESS:. IF BUSINESS IS NOT RATED BY DUN AND BRADSTREET, YOU ARE REQUIRED TO ATTACH A COPY OF A RECENT (WITHIN THE LAST YEAR) BALANCE SHEET. 3. APPROXIMATE INVENTORY NORMALLY STOCKED: $. 4. REFERENCE (LIST NAME AND ADDRESS): A. OTHER GOVERNMENTAL UNITS OR BUSINESSES THAT YOU HAVE SOLD TO OR SERVICED. (LIST AT LEAST THREE) NAME ADDRESS CITY, STATE, ZIP B. BANK(S) & ACCOUNT NUMBER(S) OR CONTACT PERSON(S):
4 5. ATTACH ANY ADDITIONAL INFORMATION THAT YOU WOULD LIKE TO BE CONSIDERED IN DETERMINING YOUR ELIGIBILITY TO BE PLACE ON THE BIDDERS LIST. FACTORS THAT ARE RELEVANT INCLUDE EVIDENCE OF EXPERIENCE, FINANCIAL CAPABILITY, AND QUALITY OF PERFORMANCE. SECTION C FROM THE ATTACHED COMMODITY CLASS INDEX, SELECT ONLY THOSE CLASSES AND SUB-CLASSES THAT YOU CAN FURNISH. APPLICATIONS WILL NOT BE ACCEPTED THAT SHOW ONLY COMMODITY CLASS, SUB-CLASS RANGES, OR COMMODITY DESCRIPTIONS; ALL SUB-CLASSES MUST BE INDICATED. EXAMPLE: CLASS 060 SUB-CLASS 03, 12,42, 83 THIS EXAMPLE SHOWS A REQUEST TO BE PLACED ON BIDDERS LISTS FOR ANTI-FREEZE, BATTERIES, FILTERS, AND SHOCK ABSORBERS. SEE PAGE 3 OF COMMODITY CLASS INDEX.
5 NORTH ARKANSAS COLLEGE WILL BE RESPONSIBLE ONLY FOR ORDERS PLACED BY THE PURCHASING DEPARTMENT. COMPANIES THAT ACCEPT ORDERS FROM NORTH ARKANSAS COLLEGE PERSONNEL, WITHOUT AN OFFICIAL PURCHASE ORDER, MUST LOOK TO THE INDIVIDUAL FOR PAYMENT. I, THE UNDERSIGNED HEREBY CERTIFY THAT THE ABOVE FOREGOING INFORMATION IS CORRECT AND AGREE TO FAITHFULLY ABIDE BY THE PURCHASING LAWS OF THE STATE OF ARKANSAS AND THE REGULATIONS OF THE DEPARTMENT OF FINANCE & ADMINISTRATION NOW IN EFFECT AND ANY SUBSEQUENT REVISIONS THEREOF.
6 I ALSO UNDERSTAND THAT MY FAILURE TO SUBMIT A RESPONSE TO THREE (3) BID INVITATIONS ON ANY ONE CLASS OR SUB-CLASS MAY CAUSE NORTH ARKANSAS COLLEGE TO DISCONTINUE SENDING BID INVITATIONS TO ME FOR THAT CLASS OR SUB-CLASS. SIGNATURE: NAME (TYPE OR PRINTED): TITLE (TYPED OR PRINTED): DATE:
7
8 SUB-CLASSES, SUB-CLASSES, SUB-CLASSES, SUB-CLASSES, SUB-CLASSES, SUB-CLASSES,
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