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Vendorapp - vendorapp

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File type: PDF

U.S.A. forms for Louisiana State University

BROWSE LOUISIANA STATE UNIVERSITY FORMS

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1
Louisiana State University
Procurement Office
Vendor Enrollment Application Form
Vendor Name _______________________________________________________________________
[required]
Division/DBA ____________________________________________________________
Business URL
_______________________________________________________________________
[optional]
Tax ID Number
[FEIN/SSN] _____________________________________________________________________
[required]
Business Organization Type
[required; select one]
Corporation Corporation – Legal Services Corporation – Medical Services
Limited Liability Company Individual Partnership Other
Submitted By
Name _________________________________________________________________________
[required]
Phone _________________________________________________________________________
Business Ownership Certifications
[optional; check all that apply]
Minority Owned Business – Federally Certified
Woman Owned Business – Federally Certified
Small Business – Federally Certified
Emerging Business – LA Dept of Economic Development Certified
Affidavit: By marking any ‘Business Ownership Certification’ on the LS
U Vendor Enrollment Application form, the
Vendor agrees to a self-certification process and solemnly affirms and attests that it possesses any claimed federal
and/or state certification(s); and agrees to provide LSU with supporting evidence of such at any time upon request.
The Vendor acknowledges that its willful and false claim of these certifications may result in contract cancellations
and/or suspension or debarment proceedings. The Vendor further accepts the responsibility to promptly report any
certification changes to the LSU Procurement Office.
Taxpayer Identification Number (TIN) Certification [required]
Check your responses to the three statements shown below, as made and certified on your Company’s Federal IRS
Form W-9.
Under penalties of perjury, I certify that:
I am not subject to backup withholding.
I am a U.S. person (including a U.S. resident alien).
The number (FEIN or SSN) shown on this form is my correct taxpayer identification number.
Note: Additional information and instructions regarding these certifications are found on IRS Form W-9.
2
State Region Enrollment [required]
Vendors must express their interest by self-enrolling in their desired State of Louisiana Region(s) in which they are
willing and able to conduct responsible business. Vendors must enroll in at least one (1) state delivery region;
however, may enroll in multiple or all state regions as desired.
LSU campuses using the e-PRO Vendor Database are located in the following state regions:
• Baton Rouge - Region 2 • Eunice - Region 4 • Alexandria - Region 6
Note: LSU AgCenter Research Stations are regionally located statewide.
Check those State Regions in which you wish to participate/enroll:
1 2 3 4 5 6 7 8 All Regions
Baton Rouge Eunice Alexandria
Mail-To Address [required; used by LSU Procurement to send solicitations, addenda, purchase orders,
change orders, and purchasing correspondence via E-Mail, Fax, and/or USPS Mail]
Address _______________________________________________________________________________
_______________________________________________________________________________
City _______________________________________________________________________________
State _________
Zip Code / + 4 ____________ / ________ Country _____________________________
Phone/Ext ____________________________________ Toll Free/Ext ___________________________________
Fax _________________________________________ E-mail ________________________________________
Mail-To Contact [required]
Name and Title ________________________________________________________________________________
Ship-To Address [required if different from Mail-To address information; used by LSU Procurement to send purchasing
transactions via courier/express service]
Same as Mail-To Address Different as indicated below
Address _______________________________________________________________________________
_______________________________________________________________________________
City _______________________________________________________________________________
State _________ Zip Code / + 4 ____________ / ________ Country _____________________________
Phone/Ext ____________________________________ Toll Free/Ext ___________________________________
Fax _________________________________________ E-mail ________________________________________
Ship-To Contact
[required if different from Mail-To contact information]
Same as Mail-To Contact Different as indicated below
Name and Title ________________________________________________________________________________
3
Remit-To Address [required if different from Mail-To or Ship-To address information; used by LSU Accounting
Payable to send payments and accounting correspondence]
Same as Mail-To Address Same as Ship-To Address Different as indicated below
Address _______________________________________________________________________________
_______________________________________________________________________________
City _______________________________________________________________________________
State _________ Zip Code / + 4 ____________ / ________ Country _____________________________
Phone/Ext ____________________________________ Toll Free/Ext ___________________________________
Fax _________________________________________ E-mail ________________________________________
Remit-To Contact
[required if different from Mail-To or Ship-To contact information]
Same as Mail-To Contact Same as Ship-To Contact Different as indicated below
Name and Title ________________________________________________________________________________
Commodity Enrollment
[required]
Vendors must enroll in at least one (1) commodity class-subclass; however, may enroll in as many commodity class-
subclasses as desired. Enrollment at the general 3-digit commodity class level for inclusion in all associated
subclasses is not allowed.
Complete the attached ‘Commodity Class-Subclass Enrollment’ form.
The LSU Commodity Code List, inclusive of detailed class-subclass descriptions, is accessible electronically at
our website, www.fas.lsu.edu/purchasing/commcode.htm. Vendors without internet service may visit any local library
or university offering free public access to the internet, or may visit their LSU Procurement Office to manually
review the Commodity Code List.
~~~~~~~~~~
If you have any questions or need assistance with vendor enrollment, please contact the LSU Procurement Office
[ph
(225) 578-2176 / fax (225) 578-2292 / e-mail purchase@lsu.edu]. Return your completed application and
commodity enrollment form to:
Louisiana State University
Procurement Office
213 Thomas Boyd Hall
Baton Rouge, LA 70803
~~~~~~~~~~
THANK YOU FOR ENROLLING WITH LSU!
4
Louisiana State University
Procurement Office
Commodity Code Enrollment Form
Vendor Name
_______________________________________________________________________
Tax ID Number
[FEIN/SSN] _____________________________________
Vendors must enroll in at least one (1) commodity class and subclass; however, may enroll in as many
commodities as desired. Enrollment at the general 3-digit commodity class level for inclusion in all
associated subclasses is not allowed.
Enter the LSU Commodity Class and
Subclass Numbers below for those goods and/or services for which
you wish to be considered for LSU procurement opportunities.
Class Sub Class Sub Class Sub Class Sub Class Sub Class Sub
Make additional
copies of this form if necessary for additional commodity class-subclass enrollments.
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Completed 20 February 2020

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