ESIT Contacts:

/ Intake Form
In order to prepare a Contract, the state of Washington Department of Early Learning (DEL), needs the following information. More information is available below on page 3.
CONTRACTOR INFORMATION
LEGAL NAME (as legally registered with the IRS) / DOING BUSINESS AS (DBA)
WEB SITE:
MAILING ADDRESS / WA UNIFORM BUSINESS IDENTIFIER (UBI)
WA STATEWIDE PAYEE NUMBER
CONTRACT CONTACT* - see page 2 / TELEPHONE / E-MAIL ADDRESS
FISCAL CONTACT / TELEPHONE / E-MAIL ADDRESS
SIGNATORY / TELEPHONE / E-MAIL ADDRESS
FEDERAL ID NUMBER / Have you had any contract to provide services terminated for default?
Yes No
Are you currently Debarred from federal or state contracting?
Yes No
DUNS NUMBER
(See information on page 3 for DUNS number.)
If services are being provided for specific Counties, please list the Washington Counties where youwill be providing services? (Use ‘Statewide’ if all Counties)
Isanyone benefiting from this contract a retired Washington State Employee? / Yes No
If yes, please see the retirement information below.
Are any of your employees, current employees of the State of Washington?
Yes No / If yes, those persons who are also current employees of the State of Washington must complete an Ethics Certification forCurrent Washington State Employees.(See below for more information.)
Are you a Washington Defined Small Business? (See definition on page 3) / Yes No
Are you registered by the Veteran’s Administration as a Veteran Owned business? / Yes No
(Visitfor information about registration)
Are you certified by the Office of Minority and Women’s Business Enterprises (OMWBE) / Yes No
(Visit for information about certification)

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ESIT Contacts:

Name of Statewide Services

Please complete the following information, if not already provided on page 1. If any of the following contacts have phone numbers or addresses different from what is on page 1, such as working in another town, etcplease cut and paste the lines below after each person listed, as appropriate.

Mailling Address: / Toll Free
Phyusical Address / TTY
City State & Zip / Website

*The Primary Contact Person for this Contract is: (This person is responsible to ensure Contract implementation; will be listed as the Contract Contact on the face of the Contract. The person identified agrees to receive all Early Support for Infants and Toddlers (ESIT) communications; will ensure appropriate agency personnel are either informed of and/or receive all communications that require a response or an action; and will be listed as the Statewide Services Contact on ESIT’s distribution lists and website.)

Name: / Title

The Program Contact Person, if different from above, for this Contract is:

Name: / Title
Email: / Phone:

The Primary Fiscal Contact Person for this Statewide Contract is: (This person completes and sends the monthly billing for work completed under this Contract; is the one ESIT staff will contact when there is a question regarding the A-19A Invoice Voucher or fiscal matters.)

Name: / Title
Email: / Phone:

If applicable, the Contact Person to receive the ESIT Contacts Directory distribution list updates, for this Statewide Contract is:

Name: / Title
Email: / Phone:
Name of the person completing this form: / Date:

To expedite your contract, please return these completed forms by email to

.

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Instructions & Definitions

Uniform Business Identifier (UBI)

A Washington State business license is required prior to contracting for services in Washington. The license can be easily applied for and paid online. Go to the website under I need to… select “Get business licensing and renewal information (BLS)”.

Statewide Payee Number

In order to receive payment for services or products provided to a state agency, you must register with the Statewide Payee Desk. When you register you may choose to have your payments directly deposited to your bank or mailed to you as a check. Nopayment shall be made until the Statewide Payee Registration is complete.

DUNS Number

In the event that the contract resulting from this bid includes federal funds the contractor upon entering into a contract will be required to have a Data Universal Numbering System (DUNS) number. Information on how to obtain a DUNS number can be found at the following location:

Washington State Retiree

If anyone who is receiving retirement through a 2008 early retirement program with the State of Washington may not receive monetary gain from the State of Washington AND their retirement funds concurrently. Due to concerns regarding the security of the confidential Social Security numbers, please have the retiree call DEL Contract Office, at (360)725-4914, to supply them with the name of your company or the contract number, the exact spelling of the retirees name and their Social Security Number. Then DEL will confidentially verify the information supplied through the DRS Member Reporting & Verification System to ensure that the retiree is not part of the 2008 Early Retirement factors.

Ethics Certification

If a current state employee or officer is contracting as an individual with DEL, an ethics approval may be required: a state officer or employee must receive ethics board approval before entering into, or obtaining a beneficial interest in, a contract or grant with a state agency only if the process for awarding the contract or grant was not open and competitive, or, whenever only one bid or application was received. So, a board member who is a current state employee and is not receiving funds directly from the contract does not need to have Ethics board review.

Go to: and select “Contracting with the State” and follow the instructions.

"Small business" "Small business" means an in-state business, including a sole proprietorship, corporation, partnership, or other legal entity, that: (a) Certifies, under penalty of perjury, that it is owned and operated independently from all other businesses and has either: (i) Fifty or fewer employees; or (ii) A gross revenue of less than seven million dollars annually as reported on its federal income tax return or its return filed with the department of revenue over the previous three consecutive years; or (b) Is certified with the office of women and minority business enterprises under chapter 39.19 RCW.

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