Fillable Form 1.: POTENTIAL VENDOR INFORMATION Anyone conducting business (Navarro College)

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Form 1.: POTENTIAL VENDOR INFORMATION Anyone conducting business (Navarro College)

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POTENTIAL VENDOR INFORMATION

Anyone conducting business with Navarro College must submit the following

documents and information to the purchasing office prior to a contract or

purchase order being issued.

Vendor Information Form

IRS W9 Form

References

Conflict of Interest Questionnaire (required is any relationship exists with

college staff or members of Board of Trustees)

Felony Conviction Notification Form - Please contact our office if you

need this form.

Sole Source Providers must submit a completed Sole Source Provider Form.

Vendors on state contract or part of a state-approved purchasing cooperative

must provide a letter on company letterhead providing names of cooperatives,

state contract numbers, and any other identification numbers necessary to

process a purchase requisition if that information is not provided on the Vendor

Information Form.

All purchases made by Navarro College will be FOB Destination.

All vendors must provide Navarro College with a designated contact person,

telephone number(s), and email address.

Navarro College places all bids on the State of Texas Electronic State Business

Daily at esbd.cpa.state.tx.us/

Navarro College is a member of several purchasing cooperatives. Please

contact the Purchasing department if you are an approved vendor on a

purchasing cooperative in the State of Texas and would like to do business with

Navarro College.

Orders placed without a signed purchase order will not be honored by Navarro

College.

Email susan.hemsworth@navarrocollege.edu for information.

Vendor Information Form

To become a potential vendor and/or to receive bids, please fill out the Vendor Information Form below.

The Vendor Information Form, a current W9, and Conflict of Interest Questionnaire (if applicable) may be

mailed to the Purchasing Department located on the Corsicana Campus at 3200 W. 7

Avenue, Corsicana,

Texas 75110 or it can be faxed to (903) 874-4636.

Company Information

Company Name________________________________________________________________

Physical Address_______________________ City __________________ State_____ Zip_____

Mailing Address_______________________ City __________________ State _____ Zip_____

Phone________________________________ Fax_____________________________________

Name of Contact Person______________________________ Title________________________

E-mail Address of Contact Person__________________________________________________

Type of Organization

Do you provide Products _____ Services _____

What type of products/services do you offer __________________________________________

______________________________________________________________________________

Please Indicate if Your Company is a member of a Purchasing Cooperative

E & I Yes_____ No_____ If Yes, Provide Contract Number_____________________

TXMAS Yes_____ No_____ If Yes, Provide Contract Number_____________________

BUYBOARD Yes_____ No_____ If Yes, Provide Contract Number_____________________

Other: Yes_____ No_____ If Yes, Provide Name of Co-Op and Contract Number

__________________________________________________________________________________

Vendors Must Disclose:

1. If any of its employees, officers, directors, subcontractors or agents are related to or are members of the board

of trustees or an employee of the district; and

2. If the owner or operator of the company has ever been convicted of, or is currently charged with, a felony.

3. Persons submitting a response to this solicitation must comply with all applicable laws, ordinances and

regulations including the provisions of the State of Texas Government Code Chapter 176. As applicable, the

person submitting the response must complete and submit a Conflict of Interest Questionnaire form CIQ, in a

format approved by the Texas Ethics Commission.

Authorized Signature: ________________________________________ Date: ______________________

Printed Name: _______________________________________________

click to sign

signature

click to edit

Give form to the

requester. Do not

send to the IRS.

Form W-9

Request for Taxpayer

Identification Number and Certification

(Rev. January 2003)

Department of the Treasury

Internal Revenue Service

Name

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. 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

––

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

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

䊳

Date

䊳

Purpose of Form

Form W-9 (Rev. 1-2003)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

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,

3. Claim exemption from backup withholding if you are a

U.S. exempt payee.

Foreign person. If you are a foreign person, use the

appropriate Form W-8 (see Pub. 515, Withholding of Tax on

Nonresident Aliens and Foreign Entities).

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

䊳

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.

Nonresident alien who becomes a resident alien.

Generally, only a nonresident alien individual may use the

terms of a tax treaty to reduce or eliminate U.S. tax on

certain types of income. However, most tax treaties contain a

provision known as a “saving clause.” Exceptions specified

in the saving clause may permit an exemption from tax to

continue for certain types of income even after the recipient

has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an

exception contained in the saving clause of a tax treaty to

claim an exemption from U.S. tax on certain types of income,

you must attach a statement that specifies the following five

items:

1. The treaty country. Generally, this must be the same

treaty under which you claimed exemption from tax as a

nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that

contains the saving clause and its exceptions.

4. The type and amount of income that qualifies for the

exemption from tax.

5. Sufficient facts to justify the exemption from tax under

the terms of the treaty article.

Form W-9 (Rev. 1-2003) Page 2

Sole proprietor. Enter your individual name as shown on

your social security card on the “Name” line. You may enter

your business, trade, or “doing business as (DBA)” name on

the “Business name” line.

Other entities. Enter your business name as shown on

required Federal tax documents on the “Name” line. This

name should match the name shown on the charter or other

legal document creating the entity. You may enter any

business, trade, or DBA name on the “Business name” line.

If the account is in joint names, list first, and then circle,

the name of the person or entity whose number you entered

in Part I of the form.

Limited liability company (LLC). If you are a single-member

LLC (including a foreign LLC with a domestic owner) that is

disregarded as an entity separate from its owner under

Treasury regulations section 301.7701-3, enter the owner’s

name on the “Name” line. Enter the LLC’s name on the

“Business name” line.

Specific Instructions

Name

Exempt From Backup Withholding

Generally, individuals (including sole proprietors) are not

exempt from backup withholding. Corporations are exempt

from backup withholding for certain payments, such as

interest and dividends.

5. You do not certify to the requester that you are not

subject to backup withholding under 4 above (for reportable

interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup

withholding. See the instructions below and the separate

Instructions for the Requester of Form W-9.

Civil penalty for false information with respect to

withholding. If you make a false statement with no

reasonable basis that results in no backup withholding, you

are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully

falsifying certifications or affirmations may subject you to

criminal penalties including fines and/or imprisonment.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN

to a requester, you are subject to a penalty of $50 for each

such failure unless your failure is due to reasonable cause

and not to willful neglect.

Misuse of TINs. If the requester discloses or uses TINs in

violation of Federal law, the requester may be subject to civil

and criminal penalties.

If you are an individual, you must generally enter the name

shown on your social security card. However, if you have

changed your last name, for instance, due to marriage

without informing the Social Security Administration of the

name change, enter your first name, the last name shown on

your social security card, and your new last name.

Exempt payees. Backup withholding is not required on any

payments made to the following payees:

1. An organization exempt from tax under section 501(a),

any IRA, or a custodial account under section 403(b)(7) if the

account satisfies the requirements of section 401(f)(2);

2. The United States or any of its agencies or

instrumentalities;

3. A state, the District of Columbia, a possession of the

United States, or any of their political subdivisions or

instrumentalities;

4. A foreign government or any of its political subdivisions,

agencies, or instrumentalities; or

5. An international organization or any of its agencies or

instrumentalities.

Other payees that may be exempt from backup

withholding include:

6. A corporation;

7. A foreign central bank of issue;

8. A dealer in securities or commodities required to register

in the United States, the District of Columbia, or a

possession of the United States;

If you are exempt, enter your name as described above and

check the appropriate box for your status, then check the

“Exempt from backup withholding” box in the line following

the business name, sign and date the form.

4. The IRS tells you that you are subject to backup

withholding because you did not report all your interest and

dividends on your tax return (for reportable interest and

dividends only), or

3. The IRS tells the requester that you furnished an

incorrect TIN, or

2. You do not certify your TIN when required (see the Part

II instructions on page 4 for details), or

You will not be subject to backup withholding on payments

you receive if you give the requester your correct TIN, make

the proper certifications, and report all your taxable interest

and dividends on your tax return.

1. You do not furnish your TIN to the requester, or

What is backup withholding? Persons making certain

payments to you must under certain conditions withhold and

pay to the IRS 30% of such payments (29% after December

31, 2003; 28% after December 31, 2005). This is called

“backup withholding.” Payments that may be subject to

backup withholding include interest, dividends, broker and

barter exchange transactions, rents, royalties, nonemployee

pay, and certain payments from fishing boat operators. Real

estate transactions are not subject to backup withholding.

Payments you receive will be subject to backup

withholding if:

If you are a nonresident alien or a foreign entity not

subject to backup withholding, give the requester the

appropriate completed Form W-8.

Example. Article 20 of the U.S.-China income tax treaty

allows an exemption from tax for scholarship income

received by a Chinese student temporarily present in the

United States. Under U.S. law, this student will become a

resident alien for tax purposes if his or her stay in the United

States exceeds 5 calendar years. However, paragraph 2 of

the first Protocol to the U.S.-China treaty (dated April 30,

1984) allows the provisions of Article 20 to continue to apply

even after the Chinese student becomes a resident alien of

the United States. A Chinese student who qualifies for this

exception (under paragraph 2 of the first protocol) and is

relying on this exception to claim an exemption from tax on

his or her scholarship or fellowship income would attach to

Form W-9 a statement that includes the information

described above to support that exemption.

Note: You are requested to check the appropriate box for

your status (individual/sole proprietor, corporation, etc.).

Note: If you are exempt from backup withholding, you should

still complete this form to avoid possible erroneous backup

withholding.

Form W-9 (Rev. 1-2003) Page 3

Part I. Taxpayer Identification

Number (TIN)

Enter your TIN in the appropriate box. If you are a resident

alien and you do not have and are not eligible to get an

SSN, your TIN is your IRS individual taxpayer identification

number (ITIN). Enter it in the social security number box. If

you do not have an ITIN, see How to get a TIN below.

How to get a TIN. If you do not have a TIN, apply for one

immediately. To apply for an SSN, get Form SS-5,

Application for a Social Security Card, from your local Social

Security Administration office or get this form on-line at

www.ssa.gov/online/ss5.html. You may also get this form

by calling 1-800-772-1213. Use Form W-7, Application for

IRS Individual Taxpayer Identification Number, to apply for an

ITIN, or Form SS-4, Application for Employer Identification

Number, to apply for an EIN. You can get Forms W-7 and

SS-4 from the IRS by calling 1-800-TAX-FORM

(1-800-829-3676) or from the IRS Web Site at www.irs.gov.

If you are asked to complete Form W-9 but do not have a

TIN, write “Applied For” in the space for the TIN, sign and

date the form, and give it to the requester. For interest and

dividend payments, and certain payments made with respect

to readily tradable instruments, generally you will have 60

days to get a TIN and give it to the requester before you are

subject to backup withholding on payments. The 60-day rule

does not apply to other types of payments. You will be

subject to backup withholding on all such payments until you

provide your TIN to the requester.

If you are a sole proprietor and you have an EIN, you may

enter either your SSN or EIN. However, the IRS prefers that

you use your SSN.

If you are a single-owner LLC that is disregarded as an

entity separate from its owner (see Limited liability

company (LLC) on page 2), enter your SSN (or EIN, if you

have one). If the LLC is a corporation, partnership, etc., enter

the entity’s EIN.

Note: See the chart on page 4 for further clarification of

name and TIN combinations.

Note: Writing “Applied For” means that you have already

applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded domestic entity that has a foreign

owner must use the appropriate Form W-8.

9. A futures commission merchant registered with the

Commodity Futures Trading Commission;

10. A real estate investment trust;

11. An entity registered at all times during the tax year

under the Investment Company Act of 1940;

12. A common trust fund operated by a bank under

section 584(a);

13. A financial institution;

14. A middleman known in the investment community as a

nominee or custodian; or

15. A trust exempt from tax under section 664 or

described in section 4947.

THEN the payment is exempt

for . . .

If the payment is for . . .

All exempt recipients except

for 9

Interest and dividend payments

Exempt recipients 1 through 13.

Also, a person registered under

the Investment Advisers Act of

1940 who regularly acts as a

broker

Broker transactions

Exempt recipients 1 through 5Barter exchange transactions

and patronage dividends

Generally, exempt recipients

1 through 7

Payments over $600 required

to be reported and direct

sales over $5,000

See Form 1099-MISC, Miscellaneous Income, and its instructions.

However, the following payments made to a corporation (including gross

proceeds paid to an attorney under section 6045(f), even if the attorney is a

corporation) and reportable on Form 1099-MISC are not exempt from backup

withholding: medical and health care payments, attorneys’ fees; and payments

for services paid by a Federal executive agency.

The chart below shows types of payments that may be

exempt from backup withholding. The chart applies to the

exempt recipients listed above, 1 through 15.

Form W-9 (Rev. 1-2003) Page 4

What Name and Number To Give the

Requester

Give name and SSN of:For this type of account:

The individual1. Individual

The actual owner of the account

or, if combined funds, the first

individual on the account

2. Two or more individuals (joint

account)

The minor

3. Custodian account of a minor

(Uniform Gift to Minors Act)

The grantor-trustee

4. a. The usual revocable

savings trust (grantor is

also trustee)

1. Interest, dividend, and barter exchange accounts

opened before 1984 and broker accounts considered

active during 1983. You must give your correct TIN, but you

do not have to sign the certification.

The actual owner

b. So-called trust account

that is not a legal or valid

trust under state law

2. Interest, dividend, broker, and barter exchange

accounts opened after 1983 and broker accounts

considered inactive during 1983. You must sign the

certification or backup withholding will apply. If you are

subject to backup withholding and you are merely providing

your correct TIN to the requester, you must cross out item 2

in the certification before signing the form.

The owner

5. Sole proprietorship or

single-owner LLC

Give name and EIN of:For this type of account:

3. Real estate transactions. You must sign the

certification. You may cross out item 2 of the certification.

A valid trust, estate, or

pension trust

Legal entity

4. Other payments. You must give your correct TIN, but

you do not have to sign the certification unless you have

been notified that you have previously given an incorrect TIN.

“Other payments” include payments made in the course of

the requester’s trade or business for rents, royalties, goods

(other than bills for merchandise), medical and health care

services (including payments to corporations), payments to a

nonemployee for services, payments to certain fishing boat

crew members and fishermen, and gross proceeds paid to

attorneys (including payments to corporations).

The corporationCorporate or LLC electing

corporate status on Form

8832

The organizationAssociation, club, religious,

charitable, educational, or

other tax-exempt organization

5. Mortgage interest paid by you, acquisition or

abandonment of secured property, cancellation of debt,

qualified tuition program payments (under section 529),

IRA or Archer MSA contributions or distributions, and

pension distributions. You must give your correct TIN, but

you do not have to sign the certification.

The partnershipPartnership or multi-member

LLC

The broker or nomineeA broker or registered

nominee

10.

The public entityAccount with the Department

of Agriculture in the name of

a public entity (such as a

state or local government,

school district, or prison) that

receives agricultural program

payments

11.

Privacy Act Notice

List first and circle the name of the person whose number you furnish. If only

one person on a joint account has an SSN, that person’s number must be

furnished.

Circle the minor’s name and furnish the minor’s SSN.

You must show your individual name, but you may also enter your

business or “DBA” name. You may use either your SSN or EIN (if you have

one).

List first and circle the name of the legal trust, estate, or pension trust. (Do

not furnish the TIN of the personal representative or trustee unless the legal

entity itself is not designated in the account title.)

Note: If no name is circled when more than one name is

listed, the number will be considered to be that of the first

name listed.

Sole proprietorship or

single-owner LLC

The owner

12.

Part II. Certification

For a joint account, only the person whose TIN is shown in

Part I should sign (when required). Exempt recipients, see

Exempt from backup withholding on page 2.

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable

interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

To establish to the withholding agent that you are a U.S.

person, or resident alien, sign Form W-9. You may be

requested to sign by the withholding agent even if items 1, 3,

and 5 below indicate otherwise.

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns

with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or

abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses the

numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information

to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their

tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce

Federal nontax criminal laws and to combat terrorism.

Signature requirements. Complete the certification as

indicated in 1 through 5 below.

Adopted 06/29/2007

FORM CIQ

OFFICE USE ONLY

This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.

This questionnaire is being filed in accordance with Chapter 176, Local Government Code

by a person who has a business relationship as defined by Section 176.001(1-a) with a local

governmental entity and the person meets requirements under Section 176.006(a).

By law this questionnaire must be filed with the records administrator of the local governmental

entity not later than the 7th business day after the date the person becomes aware of facts

that require the statement to be filed. See Section 176.006, Local Government Code.

A person commits an offense if the person knowingly violates Section 176.006, Local

Government Code. An offense under this section is a Class C misdemeanor.

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor or other person doing business with local governmental entity

Check this box if you are filing an update to a previously filed questionnaire.

(The law requires that you file an updated completed questionnaire with the appropriate filing authority not

later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)

Name of person who has a business relationship with local governmental entity.

Date Received

Name of local government officer with whom filer has employment or business relationship.

Name of Officer

This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an

employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional

pages to this Form CIQ as necessary.

A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment

income, from the filer of the questionnaire?

Yes No

B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the

direction of the local government officer named in this section AND the taxable income is not received from the local

governmental entity?

Yes No

C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local

government officer serves as an officer or director, or holds an ownership of 10 percent or more?

Yes No

D. Describe each employment or business relationship with the local government officer named in this section.

Signature of person doing business with the governmental entity

Date

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