Bidder’s Application
University of Arkansas – Fort Smith Procurement Services
5317A Grand Avenue, PO Box 3649
Fort Smith, AR 72913-3649 Phone (479) 788-7070 - Fax (479) 788-7075
Please type or print. Complete sections A, B and C in their entirety.
Section A
1. Mail bid invitations to:
Name of business: ____________________________________________________________
Attention: ____________________________________________________________
Street or PO Box: ____________________________________________________________
City: ____________________________________________________________
State: _____________________________ ZIP code: ______________________
Telephone number: _____________________________ Fax number: ____________________
Email address: ____________________________________________________________
2. Federal employer ID number: ________________________________________________________
(Social Security number if applicant is an individual)
3. Home office address: ____________________________________________________________
____________________________________________________________
____________________________________________________________
NOTICE
Bidder is responsible for updating the
above information. Bids returned to UA Fort
Smith for incorrect address will cause
bidder to be removed from the mailing list.
4. Type of organization: 5. Type of business: 6. Ownership of business:
___ Individual ___ Manufacturer/Producer ___ Black, not Hispanic
___ Partnership ___ Factory Representative ___ White, not Hispanic
___ Corporation ___ Service Establishment ___ Hispanic
Date of incorporation: ___ Insurance agent/company ___ Amer. Indian/Alaskan Native
__________________ ___ Jobber ___ Asian or Pacific Islander
Which state: ___ Wholesaler
__________________ ___ Retailer
7. Do you qualify as a minority supplier? ____Yes ____ No
8. Do you qualify as a small business? ____Yes ____No
9. How long in present business? ____________________________If time period does not coincide
with date of incorporation (response to number 4), attach separate sheet with explanation.
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?
____Yes ____No
(B) Has anyone filed a complaint against you or others as listed in (A) above, or your merchandise or
service? ____Yes ____No
(C) Has a performance penalty ever been assessed against you or others as listed in (A) above? ____Yes
____No
If your response was yes to any of the questions in number 10, please attach a separate sheet with an
explanation.
11. Person(s) authorized to sign bids (this must be signed in ink and kept current):
______________________________________________________________________________________
Signature Name Title Telephone
______________________________________________________________________________________
Signature Name Title Telephone
______________________________________________________________________________________
Signature Name Title Telephone
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, copies of financial statements must be made available
if requested.
3. Approximate inventory normally stocked: $________________________________________
4. References:
(A) Other governmental units or businesses that you have sold to or serviced (list three):
Name Address City, State, ZIP
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
(B) Bank(s) and account number(s) or contact person(s):
___________________________________________________________________________________
___________________________________________________________________
5. Attach any additional information that you would like to have considered in determining your
eligibility to be placed on the bidders list. Factors that are relevant include evidence of experience,
financial capacity, and quality of performance.
Section C
From the attached commodity class index
, select only those classes and subclasses that you can furnish.
Applications will not be accepted that shows only commodity classes, subclass ranges or commodity
descriptions. All subclasses must be indicated. Attach additional pages if needed.
The following example shows a request to be placed on the bidders lists for antifreeze, batteries, filters, and
shock absorbers (see page 3 of the commodity class index):
Example: Class 060 Subclasses 03, 12, 42, 83…
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
Class ______ Subclasses ______, ______, ______, ______, ______, ______, ______, ______, ______
I, the undersigned, hereby certify that the information submitted in sections A, B, and C is a full, true, and
correct statement of the facts. I agree to faithfully abide by the procurement laws of the State of Arkansas and
regulations of the Department of Finance and administration now in effect and any subsequent revisions
thereof. I also understand and agree that it is my responsibility to inform UA Fort Smith Procurement Services
in writing of any changes to this application.
Signature:_______________________________________________________________
Name (typed or printed): __________________________________________________
Title (typed or printed): __________________________________________________
Date:
___________________________________________________________
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