Fillable Vendor Application (City of Gulfport Mississippi)

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Vendor Application (City of Gulfport Mississippi)

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  • 20 check-boxes
  • 27 other fields

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Page 1 of 2
City of Gulfport
VENDOR APPLICATION
Office of Procurement
1410 24
th
Avenue, Gulfport, MS 39501
PH:(228)868-5705 FAX:(228)868-5704
Date:
General Information & Instructions
Persons or businesses interested in doing business with the City of Gulfport must file this application with the Office of Procurement. All sections of the application
must be completed.
The application is provided as a courtesy only. An active application does not legally entitle a vendor to any particular solicitation; therefore, vendors are encouraged
to check the City’s website at www.gulfport-ms.gov for legal notices, Invitation for Bids (IFB), Request for Proposals (RFP) and Request for Qualifications (RFQ). The
Office of Procurement may also be contacted for solicitation information. See above for contact information.
Principal Business Name:
Year Business Established:
Principal Business Address:
Phone:
Fax:
City:
State:
Zip:
Remit To Address (if different from above):
Phone:
Fax:
City:
State:
Zip:
Email Address:
Website:
Primary Contact Person:
In the interest of protection for the City and its vendors,
it is mandatory for vendors to have purchase
authorization in the form of a signed Purchase Order.
This is the ONLY manner in which the City can determine
the purchase has been duly authorized by the City.
Title:
Phone:
Fax:
Email Address:
Minority/Women Business Enterprise (M/WBE) Yes______ No______ (If yes, please indicate M/WBE Classification below)
____African American ____ American Indian/Alaskan Native ____ Asian ____Hispanic ____Female
I hereby certify that all information entered on this form is true and correct.
________________________________________, ________________________________________
Print Name Signature
__________________________________________
Title
PLEASE SUBMIT THIS COMPLETED VENDOR APPLICATION AND COMMODITY LIST TO:
CITY OF GULFPORT, OFFICE OF PROCUREMENT, 1410 24
TH
AVENUE, GULFPORT, MS 39501
BY FAX TO 228-868-5704 OR BY EMAIL TO PURCHASING@GULFPORT-MS.GOV
The City of Gulfport is sales tax exempt. Our Federal Id is 64-6000413
Information below this point is FOR OFFICE USE ONLY
Date Received:
Vendor Number:
Page 2 of 2
COMMODITY / SERVICE
PLEASE PLACE AN (X) BY THE ITEM OR SERVICES YOU ARE INTERESTED IN PROVIDING.
005-Abrasives
335-Fertilizers & Soil Cond.
695-Printing & Silk Screening
010-Acoust Tile, Insulat Mat
340-Fire Protection Equip/Supplies
700-Promotions
015-Copy Machine Supplies
345-First Aid & Safety Supplies
715-Publications/Audiovisual
025-Air Compressor & Accessories
346-Emergency Medical Equip.
720-Pumps & Accessories
031-Air Conditioning & Heating
350-Flags, Poles, Banners & Access.
725-Radio & Telecommunications
041-Dogs, Bloodhound & Guard
360-Floor Covering, Install
730-Television Equipment
045-Appliances, Household
365-Floor Maint. Machines, Parts
735-Rags, Shop Towels, Wiping
050-Art Equipment & Supplies
395-Forms, Continuous, Computer
740-Refrigeratin Equipment
052-Art Objects
400-Foundry Casting, Equip.
745-Road & Highway Asphalt
055-Auto & Truck Accessories
405-Fuel, Oil, Great & Lubricant
750-Road/Highway Material
060-Auto & Truck Maint. Items
415-Furniture, Lab, Special
755-Road/Highway Equipment
065-Auto Bodies & Accessories
420-Furniture, Non-Office
765-Road/Highway Heavy Equipment
070-Auto Major Transportation
425-Furniture, Office
770-Roofing Materials
075-Auto Shop Equip. & Supplies
430-Welding Equipment
775-Safety Equipment/Apparel
078-Auto Tags
435-Germicides/personal Prod
785-School & Higher Education
080-Badges & Other ID Equipment
440-Glass & Glazing Supply
790-Seed, Sod, Soil & Inoculant
085-Bags, Bagging, Ties & Erosion
445-Tools, Hand (not classified)
800-Shoes, Boots
100-Barrels, Drums, Kegs
450-Hardware, Allied Items
803-sound Systems & accessories
105-Bearings (Except Wheel)
455-Heavy Equipment
805-Sporting & Athletic Equipment
120-Boats, Motors & Marine Supplies
460-Hose, All Kinds
830-Tanks
125-Bookbinding & Book Supplies
470-Janitorial Supplies
832-Tape
135-Brick & Clay Products
485-Janitorial Supplies
855-Theatrical Equipment
145-Brushes (not classified)
490- Laboratory Equipment/Access.
863-Tires & Tubes
150-Builder’s Supplies
515-Lawn Equipment
865-Toys, Games, etc.
155-Building, Fabricated
525-Library Machines/Supplies
870-Venetion Blinds, etc.
175-Chemical Lab Equip. & Supplies
540-Lumber/Wood, Siding, Etc.
880-Water Treating Chemicals
190-Chemical, Comm, Bulk
545-Machinery & Heavy Hardware
885-Water Treating Chemicals
192-Cleaning Composition/Solvents
550-Markers, Plaques, Sign, Traffic
890-Water Sewage Treatment Equip.
195-Clocks
555-Marking Devices
895-Welding Equipment/Supplies
200-Clothing & Apparel
560-Material Handling Equipment
900-Pipes, Fittings, Valves
205-Computers, DP & Word Proc.
565-Memberships/Subscriptions
905-Aircraft Operations
208-Computer Software
570-Metals; Bars, Plates, Rods
910-Buidling Maintenance/Repair
210-Concrete & Corrugated Metal
575-Microfiche, Microfilm
915-Communications/Media Serv.
215-Consultant/Contractor/Eng/Arch
578-Miscellaneous
920-DP Processing & Software
220-Control, Indica, Record Inst.
595-Nursery Stock & Supplies
924-Educational Services
225-Cooler, Drinking Water
600-Office Machines & Accessories
925-Equipment Maint. & Repair
232-Crafts, General
610-Office Supplies, Paper/Ribbon
930-Equipment Rental/Lease
265-Drapes, Curtains, Upholstery
615-Office Supplies
932-Financial Services
280-Electrical Cables, Wires
620-Office Supplies; Inks, Leads
935-Health Related Services
285-Electrical Equipment & Supply
630-Paint, Coatings, Wallpaper
945-Library Services
287-Electronic Components
635-Painting Equipment & Access.
947-Miscellaneous Services
290-Energy Collecting Equipment
640-Paper & Plastic – Disposable
955-Public Works & Related Services
295-Elevators
645-Paper
958-Real Property Rental & Lease
300-Embossing/Engraving
650-Park, Playground Swimming
960-Ground & Park Services
305-Engineering Equipment
655-Photographic Equipment
965-Security, Fire & Safety Services
310-Envelopes, Plain, Printed
665-Plastics
970-Shipping & Handling
315-Epoxy Based Formulas
670-Plumbing Equipment
975-Sign Material
320-Fasteners, Fastening Devices
673-Pipe, Fittings & Valves
980-Buyer/Surplus Property
325-Food & Beverages
675-Poisons, Agric. & Industrial
995-Public Works & Related Services
330-Fencing
680-Police Equipment & Supplies
OTHER _______________________________________________________________________________________________________________________
If you do not see your commodity or service listed above, please choose the one that closely resembles your product or service.
Form COG- W-9 (Rev. Dec 2015)
Part III: Direct Payment Information
Instructions
Attach verification of financial institution &
account. Acceptable verification
states the
business name or individual’s name, account
number and bank’s routing number imprinted on
the document. Verification can be in the form of:
1. A voided check/photocopy of check
2. Printout of bank statement
3. Or letter from financial institution.
DEPOSIT SLIPS CANNOT BE ACCEPTED
I authorize the City of Gulfport (the City) to directly deposit funds in the financial institution listed below. I
understand that it may take up to 5 days to process this request and that my first check may not be deposited. I will
verify processing with my financial institution by reviewing my statement and emailed deposit advice.
I understand that if funds that I am not entitled are deposited in my account, then the City will initiate a correcting
(debit) entry. I acknowledge that this authorization may be rejected or discontinued by the City at any time. If any of
the above information changes, I understand that it is my responsibility to complete a new enrollment/change form.
If making a change, I understand that if the direct deposit is not stopped before closing an account, the funds will be
returned to the City for distribution, and will result in a delayed check.
I agree to the terms above and would like to be paid via Direct Deposit. Yes No
Name of Financial Institution
Type of Account
Checking Savings
ABA Bank Routing Number (must be 9 digits)
Account Number (NOT including check number)
Part IV:
Sign Here
Authorized Signature ► Date ►
For Official Use
Date
Products/ Services to be provided by this vendor:
Request to: Add Vendor
Edit Vendor
Requestor Approval
►
W-9 -Substitute
City of Gulfport Substitute W-9
Rev. December 2015
Request for Vendor
Identification Number and Certification
PRINT OR TYPE
Completed form should be given
to the requesting department.
Name (List legal name, if joint names, list first & circle the name of the person whose identification number or social security number to be entered in Part I.)
Business name (If different from above.)
Check the appropriate box:
Individual/Sole proprietor
C Corporation
S Corporation
Partnership
Estate/Trust
Limited Liability Company- Enter tax classification. (C- C Corporation/ S- S Corporation, P- Partnership) ___ Government
Other (Please explain.) ___________________________________________________
Legal Address:
number, street, and apt. or suite no. Remittance Address: if different from legal address number, street, and apt. or suite
no..
City, state and ZIP code
City, state and ZIP code
Phone #: Fax #: Email address:
Part I: Identification Number
Enter your E
IN in the appropriate box.
For individuals, this is your social security number (SSN).
For other entities, it is
your employer identification number (EIN).
Vendors:
Please provide your Privilege/Business License Number.
Social security number
- -
OR
Employer identification number
-
Privilege/Business License Number
Part II: Certification
Under penalties of perjury, I certify that:
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
2. 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
Services (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
3. I am currently a City of Gulfport employee or have been an employee of the City of Gulfport within the previous twelve (12) months:
Yes____ No _____ (check one). My spouse is currently a City of Gulfport employee or has been an employee of the City of Gulfport within the
previous twelve (12) months: Yes____ No _____ (check one). The business identified in this form above _______ does _______ does not (check
one) currently employ someone who is a City of Gulfport employee or has a City employee who has an ownership interest in the business.
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Vendor Application (City of Gulfport Mississippi)

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Completed 15 July 2020

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