Moraine Valley Community College Purchasing Department
9000 West College Parkway
Palos Hills, Illinois 60465
Room L187
708 974 5703 Fax: 708 974 5245
Thank you for your interest in Moraine Valley Community College. The College will endeavor to include
your name on our vendor’s list for the supplies or services you have indicated. The College will make
every effort to inform you of our needs either via phone, email or by sending you a Request for Proposal,
Request for Bid, or Request for Quotation. Completion of this form does not guarantee business. Please
visit the College’s Web Site at
a-bid/ for a listing of current bids and proposals.
1. Contact Information
Business Name or Name of Individual:
Mailing Address:
Contact Name:__________________________________________________________________________
Phone Number:_________________________________________________________________________
Remit Address:
Remit Contact:__________________________________________________________________________
Remit Phone Number:____________________________________________________________________
Remit Fax: _____________________________________________________________________________
Remit Email:____________________________________________________________________________
2. Business Organization
Please check the appropriate form of business organization below:
___Corporation ___Sole Proprietor ___Individual ___Partnership
Please list the names of Corporate Officers and Directors:
3. MBE/FBE/DBE/PBE/VOB Certification, if applicable
__Certified Minority Business Enterprise (MBE) __Certified Female Business Enterprise (FBE)
__Disadvantaged Business Enterprise (DBE) __Veteran Owned Business (VOB)
---Certified Persons with Disabilities Business Enterprise (PBE)
If you selected any of the above certifications, you are required to submit a current letter of certification
with this application. To certify with the Illinois Business Enterprise Program (BEP) and review eligibility,
please go to
. For
Veteran Owned Business, under the Veterans Business Program (VBP) please go to
4. Financial Information
Date Business Established:_____________________ Bank Reference:_______________________
Bank Name:_________________________________ Phone Number:________________________
Contact Person:_______________________________________________________________________
Please provide Taxpayer Identification Number (FEIN) (Use Social Security Number if a Sole Proprietor):
Include IRS W-9 with submission of this application.
5. References
Please provide the name of at least five (5) references for your firm (use additional sheets if necessary):
Name Organization Telephone
___________________ _________________ _______________
___________________ _________________ _______________
___________________ _________________ _______________
___________________ _________________ _______________
___________________ _________________ _______________
Please provide a listing of other institutions of Higher Education that you have sold to in the last 3 years:
6. Product and Service Classifications:
Please provide a list of products and services that your company offers. Please use additional sheets if
The undersigned certifies to the following:
1. The undersigned is authorized to sign this form on behalf of applicant
2. All information shown on this form is correct. Misrepresentation of information may be cause
for removal of vendor and any other penalties
3. Laws of the State of Illinois and the Illinois Public Community College Act must be followed
Printed Name
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