Bidder's Mailing List
Application
(Check one)
Initial Application
Revised Application
Date:
Black Hawk College
Purchasing
6600-34
th
Avenue
Moline IL 61265
(309) 796-5220
INSTRUCTIONS: (Please type or print) In order to be placed on the College's Bidder Mailing List, the applicant must execute this form in accordance
with the instructions shown herein. Applicant must respond to all questions and sign in the space provided. If appropriate answer is "same," "not
applicable" or "none," applicant shall so state so as to indicate the question has not been overlooked. It is the responsibility of the applicant to notify
Black Hawk College of any and all changes in the content of this application at the time of the change. When completed, return the application to the
above address.
1. Company (Applicant's) Name:
2. Information for Bids and Purchase Orders
3. Information for Payments (Remit to)
Street Address:
Street Address:
P.O. Box or Suite:
P.O. Box or Suite:
City:
City:
State:
State:
Zip Code:
Zip Code:
Telephone Number:
Telephone Number:
Fax Number:
Fax Number:
Toll Free Number:
Toll Free Number:
Web Site Address:
E-Mail Address:
4. If a division of a Corporation,
show name and address of Parent Company
5. Federal Employer Identification Number (FEIN)
or Social Security Number
Name:
(FEIN available from Federal IRS):
Street Address:
P.O. Box or Suite:
6. Type of Organization
(check one)
City
Individual
Corporation-Incorporated
State:
Partnership
Under the laws of the
State of:
Zip Code:
Non-Profit
_____________________
Telephone Number:
Fax Number:
7. Bank Reference
(Name & Address)
8. Years in Business
Toll Free Number:
Web Site Address:
9. Net worth of this
business & all its affiliates
E-Mail Address:
10. Identify equipment, supplies, materials and/or services on which you desire to bid. Show brand names, names of manufacturers or
other information that will be helpful to buyers inviting your firm to bid on agency requests. (Additional items may be submitted on an
attached sheet.)
Check here if you sell products produced from recycled materials.
11. In compliance with the Illinois Purchasing Act, state the name of each individual having a beneficial interest of more than 7 1/2 percent
in the bidding enterprise and each individual, who, together with spouse or minor children, has a beneficial interest of more than 15
percent in the bidding enterprise. (Applies to proprietorships, partnerships, and/or corporations.)
12. If applicant is a Corporation, both of the following two columns must be completed:
(a) Corporate Officers
(b) Corporate Directors
13. Are any of the persons listed in No. 11 or No. 12 above elected officials, members of the General Assembly, State Officers, Illinois State
University Employees, Illinois State Employees or the spouse or minor child of such official, assembly member, officer or employee?
Yes
No
If answer is "Yes," explain below:
14. You must complete the following:
A. "Small Business" means a firm that is classified as such by the State of Illinois. (If the applicant's business is a co
mbination of the
following, the information should be separated and proportioned accordingly. If in business less than a year, state anticipated
dollar figures.)
(1) If a wholesale business, state annual sales for the most recently completed fiscal year: $
(2) If a retail business, state annual sales and receipts: $
(3) If a business selling services, state annual sales and receipts: $
(4) If a construction business, state annual sales and receipts: $
(5) If a manufacturer, state number of employees:
B. "Minority Owned Business" means a business concern which is at least 51 percentum owned by one or more minority persons, or
in the case of a corporation, at least 51 percentum of the stock which is owned by one or more minority persons; and the
management and daily operations of which are controlled by one or more of the minority individuals who own it. Minority shall
mean a person who is a citizen or lawful permanent resident of the United States and who is: Black, Hispanic, Asian, American or
American Indian or Alaskan Native. (For clarification of ethnic categories, contact the Minority and Female Business Enterprise
Division of the Illinois Department of Central Management Services.) UNDER THIS DEFINITION, THIS FIRM IS:
(check where appropriate)
A minority owned business
Black
Hispanic
Asian American
American Indian or Alaskan Native
Check here if you have been certified by the Minority and Female Business Enterprise Division of the Illinois Department of Central
Management Services. We reserve the right to verify this information with CMS.
C. "Female Owned Business" means a business concern which is at least 51 percentum owned by one or more females, or in the
case of a corporation, at least 51 percentum of the stock which is owned by one or more females; and the management and daily
business operations of which are controlled by one or more of the females who own it. "Female" shall mean a person who is a
citizen or lawful permanent resident of the United States and who is of the female gender. (For clarification of ethnic categories,
contact the Minority and Female Business Enterprise Division of the Illinois Department of Central Management Services.)
UNDER THIS DEFINITION, THIS FIRM IS: (check where appropriate)
Black
Hispanic
Asian American
American Indian or Alaskan Native
Other
Check here if you have been certified by the Minority and Female Business Enterprise Division of the Illinois Department
of Central Management Services. We reserve the right to verify this information with CMS.
D. "Not for Profit Agency for the Severely Disabled" shall be one which:
(1) complies with Illinois laws governing not-for-profit organizations
(2) is certified as a sheltered workshop by the Wage and Hour Division of the U.S. Department of Labor meets
the IDORS Just
Standards for rehabilitation facilities. UNDER THIS DEFINITION, THIS FIRM IS: (check where appropriate)
A not-for-profit agency for the severely disabled.
E. Large Business
F. Labor - Surplus Area Concern
G. Other (i.e., Non-Profit, Foreign, Public Sector)
15. Details of Ownership: Identify those who own 5 percent or more of the firm's ownership. (If additional space is needed, please attach
information with reference to #15.)
Name/Address
Race
Sex
Years of
Ownership
Ownership
Percentage
Voting
Percentage
16. Control of Firm: Identify by name and title (also race and sex for minority and/or female preference) in the firm those individuals
(including owners and non-owners) who are responsible for day-to-day management and policy decision making, including, but not
limited to, those with prime responsibility for:
A. Financial Decisions
B. Management
C. Estimating
D. Marketing and Sales
E. Hiring and Firing of Personnel
F. Purchasing of major items, supplies
17. Describe or attach a copy of any stock options, or ownership options that are outstanding, and any agreements between owners or
between owners and third parties which restrict ownership or control or minority or female owners.
18. Identify any owner (question #15) or management official (question #16) of the named firm who is or has been an employee of another
firm that has an ownership interest in or present business relationship with the named firm. Present business relationships include
shared space, equipment, financing or employees as well as both firms having some of the same owners.
19. Is the firm authorized to do business in the State as well as locally, including all necessary business licenses?
Yes
No
If answer is "No," explain below:
APPLICANT SELF-CERTIFICATION
The undersigned applicant does swear or affirm that:
(1) The information provided in the Bidder's Mailing List Application is true at the time of signing (NOTE: Any significant modifying
information must be submitted to the college at the time of the change);
(2) Neither applicant nor any principal officer or employer, so far as is known, is now debarred or declared ineligible by and from
bidding or otherwise furnishing goods or services to the State, and;
(3) Applicant, its officers or employees, have not been convicted of bribery nor attempted bribery of an officer or employee of the
State of Illinois, nor have made an admission of guilt of such conduct that is a matter of record;
(4) Applicant is an equal opportunity employer and is in compliance with the equal opportunity requirements of state and federal laws
and the Regulations Governing Procurement and Bidding at State Systems Universities in Illinois.
All transactions will be subject to Regulations Governing Procurement and Bidding at Illinois Community College pursuant to the Illinois
Community College Act, Section 3-27.1.
Name
(typed or printed):
Subscribed and sworn before me this
______________day of _____________, 20__.
Title:
Signature:
(Notary Public Signature)
Date:
CORPORATE SEAL WHERE APPROPRIATE
ADVERTISING BUILDING MATERIALS FOOD PRODUCTS
_____0001 Newspaper _____0451
Lumber
_____1001
Bread
_____0002 Radio _____0452
Hardware
_____1002
Bakery
_____0003 Television _____0453
Key Systems
_____1003
Milk & Dairy
_____0004 Promotional Materials _____0454
Roofing Materials
_____1004
Carbonated Beverages
_____0005 Magazines _____0455
Tools, Hand
_____1005
Canned Goods
_____0456
Tools, Electric, Small
_____1006
Frozen Foods
AGRICULTURE AND FARM
_____0457
Tools,Electric, Large
_____1007
Produce
_____0051 Tractors _____0458
Glass
_____1008
Seafood
_____0052 Implements _____0459
Doors
_____1009
Meat
_____0053 Livestock Feed _____0460
Ladders
_____1010
Miscellaneous Foods
_____0054 Hay & Straw _____0461
Wire, Iron, Steel Products
_____1011
Gum, Candy, Popcorn, etc..
_____0055 Fencing _____0462
Insulation
_____0056 Drilling _____0463
Windows & Hardware FOOD SERVICE EQUIPMENT
_____0057 Other Farm Equipment _____1051
Ice Machines
_____0058 Miscellaneous Supplies
CAPS AND GOWNS
_____1052
Fryers, Ovens, etc..
_____0501
Caps & Gowns
_____1053
Dish Machies
APPLIANCES
(Rentals,Disposables, etc..)
_____1054
Other Kitchen Equipment
_____0101 Washing Machines
CONTRACTORS
_____1055
China & Glassware
_____0102 Dryers _____0551
General
_____1056
Tableware
_____0103 Refrigerators _____0552
Plumbing
_____1057
Fixtures
_____0104 Ranges _____0553
Heating, Air Conditioning, etc..
_____1058
Miscellaneous Supplies
_____0105 Televisions & VCRs _____0554
Electrical
_____0106 Sewing Machines _____0555
Roofing FORMS
_____0107 Kitchen, Small _____0556
Exterior Waterproofing
_____1101
Business
_____0108 Parts
& Caulking
_____1102
Continuous, Computer
_____0557
Concrete
ART
_____0558
Asphalt FUELS
_____0151 Equipment _____0559
Masonry & Tile
_____1151
Coal
_____0152 Supplies _____0560
Asbestos
_____1152
Fuel Oil, #2
_____0153 Clay _____0561
Painting
_____1153
Fuel, Oil #6
_____0154 Metals _____1154
Gasoline
_____0155 Plastics
DATA PROCESSING
_____1155
Natural Gas
_____0601
Computer, Mainframe
_____1156
Propane
ATHLETICS
_____0602
Peripherals, Mainframe
_____0201 Football _____0603
Computer, Micro FURNITURE
_____0202 Baseball _____0604
Peripheral, Micro
_____1201
Classroom
_____0203 Basketball _____0605
Diskettes & Tapes
_____1202
Computer
_____0204 Track _____0606
Drives & Components
_____1203
Dormitory
_____0205 Golf _____0607
Software
_____1204
Laboratory
_____0206 Tennis _____0608
Supplies
_____1205
Library
_____0207 Soccer _____0609
Terminals
_____1206
Lounge
_____0208 Volleyball _____1207
Office
_____0209 Footwear
DIPLOMAS AND COVERS
_____1208
Health Care
_____0210 First Aid & Traiing Room _____0651
Dipolomas & Covers
_____1209
Casework
_____0211 Miscellaneous Supplies
DRAPERIES GENERAL MERCHANDISE CATALOGS
AUDIOVISUAL
_____0701
Draperies
_____1251
General Merchandise Catalogs
_____0251 Projectors _____0702
Window Treatments
_____0252 Videocamera/Recorder
GROUNDS AND GOLF COURSE
_____0253 Sound Systems
EDUCATIONAL MATERIALS
_____1301
Fertilizer
_____0254 Parts & Supplies _____0751
Films, Slides, Tapes
_____1302
Seed
_____0255 Electronic Components _____0752
Publications
_____1303
Insecticides, Herbicides, etc..
_____0256 Closed Circuit _____0753
Maps
_____1304
Nursery Stock
_____0257 Recorders,Audio _____1305
Tractors
_____0258 Tape, Audio
ELECTRICAL
_____1306
Mowers
_____0259 Tape, Video _____0801
Supplies, Wiring, etc..
_____1307
Greens Mowers
_____0260 Broadcast Equipment _____0802
Transformers
_____1308
Rock & Gravel
_____0803
Light Fixtures & Lighting
_____1309
BlackTop Patch
AUTOMOTIVE
_____0804
Lamps, Incandescent
_____1310
Salt, Rock
_____0301 Cars & Trucks
& Fluorescent
_____1311
Concrete Bumper Blocks
_____0302 Tires _____1312
Sign Signing Material
_____0303 Parts
FABRIC AND TEXTILES
_____1313
Tree Removal
_____0304 Other Auto Supplies _____0851
Fabrics and Textiles
(oil, antifreeze, etc..) _____0852
Clothing, Laboratory HEALTH CARE
_____0305 Vehicles, Off-road _____0853
Uniform, Police
_____1351
Pharmaceuticals
_____0854
Uniform, Food Service
_____1352
X-ray Film
BEDDING
_____0855
Uniform, Athletic
_____1353
Miscellaneous Equipment
_____0351 Mattresses _____0856
Uniform, Band
_____1354
Miscellaneous Supplies
_____0352 Pillows _____0857
Miscellaneous Clothing
_____0353 Mattress Covers & Pads _____0858
Flags & Banners HEATING PLANT
_____0354 Linen & Towels _____1401
Cool Handling Equipment
FLOOR COVERINGS & Supplies
BOOKSTORE RESALE ITEMS
_____0901
Carpet
_____1402
Air Filters
_____0401 Soft Goods _____0902
Vinyl
_____1403
Valves
_____0402 Sundries _____1404
Parts & Supplies
_____0404 Novelties & Gift Items
FLORISTS
_____0951
Florist Shops
BLACK HAWK COLLEGE PRODUCTS AND SERVICES
Please place a checkmark ( ) next to products and/or services which you provide.
ID EQUIPMENT AND SUPPLIES PAPER AND PAPER PRODUCTS SERVICES
_____1451 Photo ID Systems _____1951
Mimeo, Duplicator, Xerographic
_____2401
Vending
_____1452 Identification Cards & Supplies _____1952
Offset
_____2402
Janitorial Services
_____1953
Cover, Card, Index
_____2403
Courier
INDUSTRIAL TECHNOLOGY
_____1954
Labels
_____2404
Dry Cleaning
_____1501 Graphic Arts _____1955
Paper Towel
_____2405
Elevator Maintenance
_____1502 Drafting Equipment _____1956
Napkins, Cups, etc..
_____2406
Exterminator
_____1503 Draftin gSupplies _____2407
Freight Company
_____1504 Duplicating Equip. & Supplies
PHOTOGRAPHIC
_____2408
Refuse Removal
_____1505 Electronics _____2001
Camera
_____2409
Motor Repair
_____1506 Shop Tools & Parts _____2002
Film
_____2410
Scientific Instrument Repair
_____1507 Fluid Power _____2003
Paper
_____2411
Musical Instrument Repair
_____1508 Woods _____2004
Chemicals
_____2412
Microcomputer Repair
_____1509 Metals _____2005
Lamps, Photo, & Projection
_____2413
Chimney Repair & Restoration
_____1510 Plastics _____2006
Miscellaneous Equipment
_____2414
Other Repairs
_____1511 Phototypesetting
& Supplies
_____2415
Audio/Visual Repairs
_____1512 Printing Presses & Equipment
PLUMBING
_____2416
Laundry
_____2051
Plumbing Supplies
_____2417
Security
INSURANCE
_____2052
Fittings, Copper
_____2418
Carpet Installers
_____1551 Insurance _____2053
Water Heaters
_____2419
Landscaping, Grading, etc..
_____2054
Heating Equipment & Supplies
_____2420
Exhaust Fan Cleaning
JANITORIAL EQUIP. & SUPPLIES
_____2421
Photo Services
_____1601
Floor Machines
PRINTING AND PUBLISHING
_____2422
Air Balancing & Controls
_____1602
Floor Care Products
_____2101
Four Color
_____2423
Moving & Storage
_____1603
Cleaners
_____2102
Yearbook
_____2424
Testing Labs
_____1604
Mops, Brooms, Cloths, etc..
_____2103
Catalog
_____2425
Leasing
_____1605
Plastic Bags & Containers
_____2104
Newpaper
_____1606
Floor Matting
_____2105
Academic Journal STADIUM AND GYMNASIUM
_____1607
Housekeeping Supplies, Motel
_____2106
Speciality
_____2451
Exercise Equipment & Weights
_____2107
Small Job
_____2452
Lockers
LIBRARY
_____2108
Tickets
_____2453
Seating
_____1651
Books & Periodicals
_____2109
Color Separations
_____2454
Acrobatic Equipment
_____1652
Bookbinding
_____2110
Publishing
_____2455
Scoreboards
_____1653
Shelving
_____2456
Timers
_____1654
Supplies PROFESSIONAL SERVICES
_____2457
Pool Supplies
_____2151
Architects
MATERIAL HANDLING
_____2152
Engineers TELECOMMUNICATIONS
_____1701
Material Handling
_____2153
Attorney
_____2501
Radios
_____2154
Physician
_____2502
Pagers
MECHANICAL MAINTENANCE
_____2155
Educator
_____2503
Batteries, Radio & Pager
_____1751
Air Conditioners
_____2156
Lecturer
_____2504
Modems & Couplers
_____1752
Absorption Units
_____2157
Entertainer
_____1753
Motors
_____2158
Computer Consultant THEATER
_____1754
Fans
_____2159
Public Relations
_____2551
Scenery Materials
_____1755
Elevator Parts
_____2160
Energy Management
_____2552
Lights, Stage
_____1756
Pumps & Meters, etc..
_____2161
Food Service Consultants
_____2553
Costumes
_____1757
Temperature Controls
_____2554
Curtais, Stage
_____1758
Compressors PUBLIC SAFETY EQUIP. & SUPPLIES
_____2555
Fabric, Muslin, etc..
_____1759
Refrigeration
_____2201
Parking Permits & Decals
_____2556
Miscellaneous Supplies
_____1760
Miscellaneous Supplies
_____2202
Parking Tickets
_____2203
Ammunition & Weapons TRAVEL
MUSIC _____2204
Security Systems & Supplies
_____2601
Air Balancing & Controls
_____1801
Pianos & Organs
_____2205
Traffic Control Materials
_____2602
Bus
_____1802
Percussion
_____2603
Car Rental
_____1803
Horns RECREATION EQUIP. & SUPPLIES
_____2604
Travel Agencies
_____1804
Strings
_____2251
Bowling
_____1805
Wind
_____2252
Outdoor Products TROPHIES AND AWARDS
_____1806
Sheet Music
_____2253
Other (Playground, etc..)
_____2651
Athletic
_____1807
Music Supplies
_____2652
Other
SAFETY EQUIPMENT
OFFICE EQUIP. & SUPPLIES
_____2301
Fire Extinguishers UPHOLSTERY AND REPAIR
_____1851
Calculators
_____2302
Fire Alarm & Detection Systems
_____2701
Upholstery and Repair
_____1852
Copiers
_____2303
Miscellaneous Supplies
_____1853
Cash Register & Coin Handling WATER TREATMENT CHEMICALS
_____1854
Dictation SCIENTIFIC
_____2751
Water Treatment Chemicals
_____1855
Time Stamps
_____2351
Biology Equipment & Supplies
_____1856
Typewriters
_____2352
Geology Equipment & Supplies WELDING
_____1857
Microfilem & Microfiche
_____2353
Geography Equip. & Supplies
_____2801
Equipment
_____1858
Check Protectors, Signers, etc..
_____2354
Chemistry Equip. & Supplies
_____2802
Supplies
_____1859
Miscellaneous Supplies
_____2355
Physics Equipment & Supplies
_____2803
Gases
_____2356
Microscopes
PAINT AND VARNISH
_____2357
Lab Animals & Specimens OTHER (Describe Fully)
_____1901
Paint & Varnish
_____2358
Instruments (Spectrophometer,
_____1902
Paint Supplies Oscilloscopes, etc..)
_____1903
Wall Coverings
_____2359
Chemicals
_____2360
Apparatus, Glassware,
Tubing, etc..
_____2361
Radiation Materials
_____2362
Miscellaneous Supplies
Please place a checkmark ( ) next to products and/or services which you provide.
BLACK HAWK COLLEGE PRODUCTS AND SERVICES
INSTRUCTIONS TO PRINTERS
FORM W-9, PAGE 1 of 4
MARGINS: TOP 13mm (
1
2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8
1
2 ") 279mm (11")
PERFORATE: (NONE)
Give form to the
requester. Do not
send to the IRS.
Form W-9
Request for Taxpayer
Identification Number and Certification
(Rev. November 2005)
Department of the Treasury
Internal Revenue Service
Name (as shown on your income tax return)
List account number(s) here (optional)
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Print or type
See Specific Instructions on page 2.
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Social security number
or
Requester’s name and address (optional)
Employer identification number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Certification
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
2.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)
Sign
Here
Signature of
U.S. person
Date
Purpose of Form
Form W-9 (Rev. 11-2005)
Part I
Part II
Business name, if different from above
Cat. No. 10231X
Check appropriate box:
Under penalties of perjury, I certify that:
3
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
TLS, have you
transmitted all R
text files for this
cycle update?
Date
Action
Revised proofs
requested
Date Signature
O.K. to print
U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a
U.S. exempt payee.
3. I am a U.S. person (including a U.S. resident alien).
A person who is required to file an information return with the
IRS, must obtain your correct taxpayer identification number
(TIN) to report, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Individual/
Sole proprietor
Corporation
Partnership
Other
Exempt from backup
withholding
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester’s form if it is
substantially similar to this Form W-9.
An individual who is a citizen or resident of the United
States,
A partnership, corporation, company, or association
created or organized in the United States or under the laws
of the United States, or
Any estate (other than a foreign estate) or trust. See
Regulations sections 301.7701-6(a) and 7(a) for additional
information.
For federal tax purposes, you are considered a person if you
are:
In 3 above, if applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership income
from a U.S. trade or business is not subject to the
withholding tax on foreign partners’ share of effectively
connected income.
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required
to pay a withholding tax on any foreign partners’ share of
income from such business. Further, in certain cases where a
Form W-9 has not been received, a partnership is required to
presume that a partner is a foreign person, and pay the
withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to
establish your U.S. status and avoid withholding on your
share of partnership income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding
withholding on its allocable share of net income from the
partnership conducting a trade or business in the United
States is in the following cases:
The U.S. owner of a disregarded entity and not the entity,
For further instructions, please visit http://www.irs.gov/pub/irs-pdf/iw9.pdf
Black Hawk College
6600 34th Avenue
Moline, IL 61265-5899
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