Winter 2008

Department Of Purchasing: Vendor Application
Applicant Information
All fields are required unless stated otherwise
Company Name
Federal Tax ID
Street Address
Apartment/Unit/Suite (optional)
City
State
Zipcode
Contact Name
Contact Title
Contact Email
Day Time Phone
Fax
Cell Phone
Do you accept purchase orders?
yes
no
How many years in present business?
Type of Organization
Individual
Partnership
Corporation
If incorporated, indicate which State
Minority Business Enterprise (MBE) / Women Business Enterprise (WBE)
Please provide the following information
Are You a Minority Business Enterprise?
Yes
No
Are You a Women Business Enterprise?
Yes
No
Minority Status
African American
Asian
Hispanic
Other
If other please describe:
Certifying Agency
City of Chicago
Chicago Minority Business Development Council (CMBDC)
Women Business Developement Center (WBDC)
U.S. Small Business Administration (SBA) 8 (A) Program
Cook County
Illinois Department of Central Management Services (CMS)
Other
If other please describe:
Officers, Members or Owners of Concern, Partnership Et
Please provide the following information
President
Vice-President
Secretary
Treasurer
Persons of Concern Authorized to Sign Bids and Contracts In Your Name
Please provide the following information
Name
Official Capacity
Name
Official Capacity
Name
Official Capacity
Owners or Partners
Commodity and Service List
Plese identify the services and/or commodities that you or your company provide. If you are a distributor, manufacturer, retailer, or wholesaler, then please indicate