Davenport University
Vendor Information Form
Must be completed in full by vendor
______
Address / Contact Information
Vendor Full Name: ______Contact Name: ______
Primary Phone Number: ______Contact Phone Number: ______
Fax Number: ______Contact Position: ______
E-Mail Address: ______
Address Line 1: ______
Address Line 2: ______
City: ______State: ______Zip: ______
1099 Number: ______D&B Number: ______NAICS Number: ______
Payment Address, if different
Address Line 1:______
Address Line 2:______
City:______State:______Zip Code:______
Parent Company (If Applicable):
Name: ______
Primary Phone Number: ______
Fax Number: ______
E-Mail Address: ______
Address Line 1: ______
Address Line 2: ______
City: ______State: ______Zip: ______
1099 Number: ______D&B Number: ______NAICS Number: ______
General Information
1. Please indicate what product or service you will be providing to DU:______
______
2. Type of ownership: Private Public (include current annual report)
3. Is your organization certified as a WBE, MBE, and/or DBE?______
If so, please indicate which one(s):______
Women Owned Business Concern – A business that is at least 51% owned by a non-minority woman who controls the daily management.
Minority Business Concern – A business at least 51% of which is owned (or, in case of publicly owned businesses, at least 51% of the stock of which is owned) by one or more
minority individuals or other individuals found to be disadvantaged as established by the U.S.
Small Business Administration and whose management and daily operations are controlled by such individuals.
Check appropriate boxes below:
African American
Hispanic American
Asian- Pacific American
Asian- Indian American
Native American (American Indian, Eskimo, Aleut, Hawaiian)
Disadvantaged Business Enterprise – at least 51% owned by one or more individuals who are both socially and economically disadvantaged; and whose management and daily business operations are controlled by one or more of the socially and economically disadvantaged individuals who own it.
Please note below which government entity or Minority Council has certified your firm as a WBE, MBE, or DBE. Enclose a copy of the certification with this form.
______
4. Current Annual sales volume (USD):______
5. Will your organization be providing legal, medical, or health services? ______
6. Will your organization’s invoices be under any name other than what is listed above? If so, please
indicate: ______
7. How long has your organization been in business? ______
8. Does your organization have a documented quality system? Yes No
9. Does your organization hold any quality certifications? Yes (List) ______No
10. How many full-time people does your organization employ? ______
11. Is your organization unionized? Yes No
12. What are your organization’s invoicing/payment terms? ______
13. What is your organization’s back order policy? ______
14. What is your organization’s return policy? ______
15. Describe your organization’s financial position (provide a current copy of your organization’s
financial statements, if available): ______
16. Please provide three references that Davenport may contact to validate your organization’s service
level. The following information is required:
a. Name of organization
b. Contact person
c. Title of contact person
d. Contact mailing address and phone number
e. Best time to contact the representative organization
17. Will your organization offer rebates/incentives to the University? Yes No
If yes, please describe: ______
18. Describe your organization’s warrantee approach with respect to the products/services it would
provide the University: ______
19. Has your organization ever refused to sign a contract at their original bid price? Yes No
If yes, please describe: ______
20. Has your organization ever filed for bankruptcy? Yes No
If yes, please describe circumstances: ______
21. Are there any recent (prior 12 months) public filings involving your organization (judgments, suits, liens, UCC, government activity)? Yes No
If yes, please describe: ______
22. Does your organization have the capacity to serve the entire University? Yes No
If no, please describe circumstances that prohibit your organization from doing so:
______
______
Completed by(Print Name:) ______
Title: ______
Organization: ______
Date (mm/dd/yyyy) ______/______/______
Please forward completed form and associated attachments to DU Procurement.
Vendor Information Form (PUR-02A) 01JAN2013
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