Shopin

 
We Care Distributor inc.
5764 old Hickory Blvd
Hermitage , TN 37076
VENDOR APPLICATION FORM   APPLICATION DATE
Fill in all spaces. Insert “NA” in blocks not applicable.
Type all entries
  REVISION DATE
DATE:
 
COMPANY HOW LONG IN PRESENT BUSINESS?
ADDRESS CITY STATE ZIP
CONTACT PERSON/REPRESENTATIVE

FAX NUMBER


PHONE AND EXTENSION

TYPE OF ORGANIZATION (Check Applicable)
INDIVIDUAL PARTNERSHIP CORPORATION
IF INCORPORATED INDICATE IN WHICH STATE
YEARS ESTABLISHED:
DO YOU ACCEPT PURCHASE ORDERS? YES NO
DO YOU ACCEPT CREDIT CARDS YES NO
CATEGORY (Check below the category which applies to the applicant)
(A)MANUFACTUREROR PRODUCER (C) RETAILER (E) DISTRIBUTOR
(B) WHOLESALER (D) MANUFACTURER’S AGENT (F) SERVICE ESTABLISHMENT
NAMES OF OFFICERS, MEMBERS OR OWNERS OF CONCERN, PARTNERSHIP, ETC.
(A) PRESIDENT (B) VICE PRESIDENT
(C) SECRETARY (D) TREASURER
(E) OWNERS, PARTNERS, OR STOCKHOLDERS  
TAXPAYERS I.D.NO.
FEIN
or  
S.S No.
INSURANCE INFORMATION (Check Applicable)
LIABILITY INSURANCE: $2,000,000 $2,500,000 $5,000,000 OTHER
Workers’ Compensation :
State Minimum Greater than Minimum
Required that CUSD be named as an Additional Insured INSURANCECO
BONDING INFORMATION (Check each area in which you have been bonded and the latest date of bonding)
Perf Bond

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Mo. Year
Payment Bond (Labor and Materials)

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Mo. Year
Builders Risk

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Mo. Year
PERSONS AUTHORIZED T O SIGN QUOTES, PROPOSALS, BIDS AND CONTRACTS:
NAME OFFICIAL CAPACITY
Average number of employees(including affiliates )for four preceding calendar quarters .   Average annual sales for
preceding three fiscal years:
 
Floor Space (Square Feet)
Manufacturing Warehouse
MINORITY/WOMEN BUSINESS ENTERPRISE
(Check One) See Definitions Below
MBE MBE / WBE WBE PBE
FOR USE BY CONTRACT COMPLIANCE ONLY
BY
DATE
MINORITY GROUP MEMBERSHIP (Check One) See Definitions Below
NOTE: DO NOT COMPLETE THIS SECTION UNLESS YOU HAVE CHECKED ONE OF THE BOXES IN THE MINORITY/WOMEN BUSINESS ENTERPRISE SECTION ABOVE
AFRICAN AMERICAN OR BLACK HISPANIC AMERICAN NATIVE AMERICAN ASIAN-PACIFIC AMERICAN
CERTIFICATION DATE ISSUED EXPIRATION
MINORITY AND WOMEN OWNED BUSINESSENTERPRISE DEFINITIONS
MINORITY BUSINESS ENTERPRISE(“MBE”) means a certified participating business at least 51 percent (51%) of which is owned and controlled by one or more members or one or more minority groups, or in the case of a publicly held corporation, 5 percent (51%) of the stock is owned by one or more members of one or more minority groups and whose daily business operations are controlled by one or more such individuals.

WOMEN’S BUSINESS ENTERPRISE(“WBE”) means a certified participating business atleast 51 percent(51%) of which is owned by one or mor e women, or in the cas e of a publicl y hel d corporation, 51 percen t (51% ) of the stock ofwhic h is owned by one or mor e wome n an d whos e daily operations are controlled by on e or mor e suchindividuals . Determination of whether a busines s is at leas t 51 percen t (51% ) owned by a woman or women shal l be mad e without regar d to community propert y laws.

BUSINESS OWNED AND OPERATED BY A PERSON WITH A DISABILITY (“PBE”)means a business concern of which at least 51 percent (51%) is owned by one or more persons with a disability, or in the case of the corporation, one in which at least 51 per centum of the stock is owned by one or more persons with a disability or by a not for profit agency for the disabled organized pursuant to Section 501 of the Internal Revenue Code 1954; and the management and daily business operations of which are controlled by one or more of the persons with a disability who own it.

MINORITY GROUP MEMBER is an individua l wh o ison e ofthe following: AFRICAN AMERICAN OR BLAC K (person s wit h origin s in any of the Blac k racial group s of Africa):
HISPANIC AMERICAN: (persons of Spanish culture with origins in Puerto Rico, Mexico, Cuba, South or Central America, Spain, Portugal or the Caribbean Islands regardless of race).
NATIVE AMERICAN : (American Indian)
ASIAN-PACIFICAMERICAN : (persons with origins from Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U.S. Trust Territories of the Pacific, Northern Marianas, Laos, Cambodia, Taiwan, or the Indian subcontinent).
 
IF YOU HAVE EVER DONE BUSINESS WITH THE SCHOOL DISTRICT UNDER ANOTHER NAME, PLEASE INDICATE NAME OR NAMES.
Give names, complete addresses, buyer’s names and phone numbers of four of your customers. (Please include Federal, State orCity Governments).
ORGANIZATION ADDRESS, STATE, ZIP BUYER PHONE NUMBER
1.
2.
3.
4.
 
Bank References
NAME OF BANK ADDRESS, STATE, ZIP CONTACT PERSON PHONE NUMBER
I certify that the information supplied herein (including all pages attached) is correct and thatneither the applicant nor any person (or concern) inany connection with the applicant as a principal or officer, so far as is known, is not debarred or otherwise declared ineligible by any public agency from furnishing materials, supplies or services to any agency thereof
 
SIGNATURE OF PERSON AUTHORIZED TO SIGN THIS APPLICATION
NAME AND TITLE OF PERSON SIGNING (Please type or print)
 
PERSONS OR BUSINESSES INTERESTED INBEING ADDED TO THE BIDDER’S LIST MUST FILE THIS APPLICATION WITH THE PURCHASING DEPARTMENT. AFTER PLACEMENT ON THE BIDDERS’ LIST, A VENDOR’S FAILURE TO RESPOND TO INVITATIONS FOR BIDS WILL BE UNDERSTOOD BY THE SCHOOL DISTRICT TO INDICATE LACK OF INTEREST AND SHALL RESULT IN THE REMOVAL OF THE VENDOR’S NAME FROM THE BIDDERS’ LIST FOR THE ITEMS CONCERNED.NOTE: ANY CHANGES TO INFORMATION SUBMITTED (ADDRESSES, AUTHORIZED PERSONNEL, ETC.,) WILL REQUIRE A REVISED COPY OF THIS FORM. ADDITIONAL FORMS MAY BE OBTAINED BY CONTACTING THE PURCHASING DEPARTMENT AT THE ADDRESS SHOWN ON THE FRONT OF THIS FORM.
VENDOR I.D. NUMBER APPROVED BY DATE W9 COMM LIST