City of Virginia Beach

Transcription

1 DEPARTMENT OF FINANCE 2388 COURT PLAZA DRIVE PURCHASING DIVISION VIRGINIA BEACH, VIRGINIA PHONE FAX /5664 October 10, 2013 To: Prospective Bidders or Offerors From: City of Virginia Beach Finance/Purchasing Division Re: Bidders Application/Doing Business with the City of Virginia Beach The City of Virginia Beach is dedicated to encouraging more minority, woman-owned and small business participation in our procurement processes. If you are not already on the city s bidders list, please take a moment to complete the attached bidders application form and return it to the following address: City of Virginia Beach Finance/Purchasing Division Princess Anne Executive Park 2388 Court Plaza Drive Virginia Beach, VA Please visit our website ( to obtain a listing of outstanding Invitation to Bids and Requests for Proposals being solicited by the City. The website also contains additional information about Doing Business with the City of Virginia Beach. If you have any questions regarding the City s procurement practices, please visit our office or call us at (757) Sincerely, Bill S. Davis Bill S. Davis, CPPO Purchasing Agent

2 BIDDER S MAILING LIST APPLICATION IF YOU WISH TO BE PLACED ON THE MAILING LIST TO RECEIVE INVITATIONS TO BID, FILL OUT AND RETURN THIS FORM. PLEASE SUPPLY A LISTING OF THE COMMODITIES, LINE CARD, AND/OR LITERATURE FOR WHICH YOU WOULD LIKE TO RECEIVE INVITATIONS TO BID. ALL INFORMATION SHOULD BE TYPED OR PRINTED. PLEASE READ CAREFULLY RETURN TO: CITY OF VIRGINIA BEACH PHONE NO. (757) FINANCE/PURCHASING DIVISION FAX NO. (757) COURT PLAZA DRIVE OR (757) VIRGINIA BEACH, VA PTIMS@VBGOV.COM DATE: CHECK ONE: INITIAL APPLICATION REVISION 1. NAME & ADDRESS OF APPLICANT (SITE): TELEPHONE NO. FAX NO. CONTACT PERSON: OFFICIAL CAPACITY: 2. NAME & ADDRESS OF PARENT COMPANY: TELEPHONE NO. FAX NO. CONTACT PERSON: OFFICIAL CAPACITY: 3. COMPLETE ADDRESS TO WHICH BID SOLICITATIONS ARE TO BE MAILED TELEPHONE NO. (IF DIFFERENT FROM ITEM #1) FAX NO. CONTACT PERSON: OFFICIAL CAPACITY: 4. IS YOUR FIRM A MINORITY BUSINESS? YES NO IF YES, PLEASE INDICATE THE MINORITY CLASSIFICATION BELOW: AFRICAN AMERICAN HISPANIC AMERICAN AMERICAN INDIAN ESKIMO ASIAN AMERICAN ALEUT OTHER; PLEASE EXPLAIN: IS YOUR FIRM WOMAN OWNED? YES NO IS YOUR FIRM A SMALL BUSINESS? YES NO IS YOUR FIRM SERVICE DISABLED VETERAN? YES NO 5. PLEASE REFER TO SECTION OF THE CITY CODE REGARDING THE CITY S INTEREST TO INCREASE MINORITY AWARENESS AND TO ENCOURAGE MINORITY PARTICIPATION IN CITY CONTRACTS. 6. EMPLOYER IDENTIFICATION NUMBER ISSUED BY THE INTERNAL REVENUE SERVICE: 7. CERTIFICATION I certify that information supplied herein (including all pages attached) is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principal or officer, so far as is known, is now debarred or otherwise declared ineligible by any agency of the Federal Government from bidding for furnishing materials, supplies, or services to the Government or any agency thereof. SIGNATURE NAME & TITLE OF PERSON AUTHORIZED TO SIGN (TYPE OR PRINT)

3 PLEASE LIST YOUR COMPANY S COMMODITIES/SERVICES BELOW; PLEASE INCLUDE LINE CARD AND/OR DESCRIPTIVE LITERATURE: THE CITY OF VIRGINIA BEACH IS AN EQUAL OPPORTUNITY EMPLOYER

4 REQUEST FOR TAXPAYER ID NUMBER AND CERTIFICATION - SUBSTITUTE FOR FORM W-9 Pursuant to Section 6109 of the Internal Revenue Code, you must furnish your Taxpayer Identification Number (TIN) to the City of Virginia Beach. If this number is not provided, you may be subject to a 28% tax on each payment. You must provide your TIN whether or not you are required to file a tax return. To avoid the 28% withholding and to ensure that accurate tax information is reported to the Internal Revenue Service, please use this form to provide the requested information. OWNER S NAME Note: If you are a sole proprietor, your name must be the same as shown on your SOCIAL SECURITY CARD. LEGAL BUSINESS NAME Note: If you are a sole proprietor your legal business name should be your doing business as or trading as name. Address City State Zip Phone. Business Type: (Check One) Corporation Government Agency Partnership Trust or Estate Sole Proprietorship/Individual Tax Exempt or Non-Profit Organization Limited Liability Co. Enter tax classification (D=disregarded entity, C=Corporation, P=Partnership) Business Activity: (Check one) Services Only Merchandise (goods) only Merchandise & Services Real Estate Rental/Lease Medical/Health Care Legal Services Business Category: (Check all that apply) African-American Owned Eskimo Owned Asian-American Owned Hispanic Owned American Indian Owned Small Business Aleut Owned Woman Owned Service Disabled Veteran Check if applicable: A Division of A Wholly-Owned Subsidiary of Non-U.S. Supplier (Same Federal Tax ID as Parent) (Different Federal Tax ID than Parent) (Primarily of Foreign Origin) (Parent Company) (Parent Company) (Country) CERTIFICATION: Under penalties of perjury, I certify that: 1. The legal name and number shown on this confirmation letter is my correct legal name and taxpayer identification number (or I am waiting for a number to be issued to me), and 2 I am not subject to back up withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the Internal Revenue Service has notified me that I am no longer subject to back up withholding: Federal Tax Identification Number OR Social Security Number NOTE: If you are a sole proprietor, you may use either your SSN or FIN, as your Taxpayer Identification Number. If you are a corporation, partnership, government entity, trust or estate, tax exempt or non-profit organization you must provide a FIN as your Taxpayer Identification Number. AUTHORIZED SIGNATURE PHONE FAX PRINTED NAME TITLE DATE City of Virginia Beach Finance Department City Hall Bldg. #1, Room 212 Virginia Beach, VA FAX

5 INTERNET ADDRESS: LOG ON TO WEB-BASED PURCHASING FOR INFORMAL (SMALL) QUOTES UNDER $50,000: CONTACT BUYER FOR YOUR COMMODITY TO ACCESS COPY OF QUOTATION.