CSU Channel Islands PDR Compliment to STD. 204 Supplier#____________________________
(Assigned by CSUCI)
This information is required from each supplier/contractor doing business with the State of California. The completed form must be on file with
California State University Channel Islands prior to payment. PLEASE USE BLACK INK, PRINT OR TYPE.
Questions? Call (805) 437-8449.
Company Name ___________________________________________
STREET/P.O. BOX ______________________________________________________________________________________
CITY, STATE, ZIP CODE _________________________________________________________________________________
SITE AREA CODE AND PHONE ___________________________________________________________________________
SITE FAX (for FAX orders) ________________________________________________________________________________
SITE E-MAIL ___________________________________________________________________________________________
CONTACT NAME _______________________________________________________________________________________
CONTACT TITLE _______________________________________________________________________________________
CONTACT AREA CODE AND PHONE # (if different from site phone) ______________________________________________
STREET/P.O. BOX ______________________________________________________________________________________
CITY, STATE, ZIP CODE __________________________________________________________________________________
SITE AREA CODE AND PHONE ____________________________________________________________________________
SITE FAX # _____________________________________________________________________________________________
SITE E-MAIL ____________________________________________________________________________________________
CONTACT NAME ________________________________________________________________________________________
CONTACT TITLE _________________________________________________________________________________________
CONTACT AREA CODE AND PHONE _ (if different from site phone) _________________________________________________
CSUCI standard terms are Net 30 unless payment discount offered.
Payment Terms:____________________________________________
Ship Via: _________________________________________________
Ship Point
Prepaid and Allowed
Contractor's license classification: ____________________________
(if class is Limited Specialty, C-61, specify specialty)
Briefly describe primary commodity, equipment or service offered:
(List one only. Enclose product line card and catalogue CD if available.)
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
WEB Site Address: ___________________________________________________________
STREET/P.O. BOX __________________________________________________________________________________________
CITY, STATE, ZIP CODE ____________________________________________________________________________________
SITE AREA CODE AND PHONE # ______________________________________________________________________________
SITE FAX # (for bid) __________________________________________________________________________________________
SITE E-MAIL ________________________________________________________________________________________________
CONTACT NAME ____________________________________________________________________________________________
CONTACT TITLE _____________________________________________________________________________________________
CONTACT AREA CODE AND PHONE # (if different from site phone) ____________________________________________________
Check all that apply:
Supplier/Contractor is certified in the following categories:
Disabled Veteran Owned Business*
Must be certified through OSBCR; 51 % ownership and
10% service-related disability.
Small Business*
Must be certified by the State of California through OSBCR
* Attach Office of Small Business Certification and Resources
(OSBCR) certification letter (formerly OSMB).
Supplier provides recycled products:
Compost and Co-Compost
Fine Printing and Writing Paper
Glass Products
Lubricating Oils
Paint
Emergency Resource Information: By providing the following information, supplier/contractor may be called upon to provide resources in the event of
a campus emergency or when the campus is designated a relief shelter for area residents by the County Emergency Services Department. This data
is confidential and will only be used in time of extreme emergencies.
Contact (after business hours):___________________________________________________________
Relation to business: _____________________
(Example: owner partner, manager)
Residence Phone: _________________________________
Cellular Phone:____________________________________
Deliver to Emergency sites? Yes No
Emergency Resource Information will be updated annually.
Supplier/Contractor's endorsement on PDR Form 204 certifies that all information provided herein is correct. Supplier/Contractor is aware of Sect. 12650 et
seq, of the Government Code which imposes treble damages for false claims against the State, and Sect. 10115,10 of the Public Contract Code making it
a crime for intentional untrue statements in this certification. .
Paper Products
Plastics
Steel
Solvents
Tire-Derived Products
Tires
Accept return of unused supplies?
