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VENDOR APPLICATON


* Required
* Vendor Name:
* Address:  * City:  * State: Zip:
* Phone / ext: * Fax: * Email:
* Contact:   * Contact Title:  Web Site:
BUSINESS CLASSIFICATION
* CHECK ALL THAT APPLY
Minority Business Enterprise (MBE)  -  Describe:
Encouraging Diversity, Growth, and Equity (EDGE)
Other (Choose all that apply)
  MBE Self-Certified Yes     No Expires: (mm/dd/yyyy)
  MBE Dayton HRC Yes     No Expires: (mm/dd/yyyy)
  Ohio EDGE Certified Yes     No Expires: (mm/dd/yyyy)
  MBE Tier II Yes     No Expires: (mm/dd/yyyy)
  WBENC Certified Yes     No Expires: (mm/dd/yyyy)
  Ohio MBE Certified Yes     No Expires: (mm/dd/yyyy)
  SCOMSDC Yes     No Expires: (mm/dd/yyyy)
TAX INFORMATION
* Federal Tax ID or SSN: * Dun & Bradstreet Number:
* Type of Legal Entity:
PAYMENT & SHIPPING
Payment Terms: Net 30 days Shipping Terms: FOB Destination
BUSINESS PROFILE
* CHECK ALL THAT APPLY
Manufacturer Wholesale/Distributor Broker Retailer
Services Construction Consultant Other
GROUP PURCHASING ORGANIZATION AFFILIATIONS
* CHECK ALL THAT APPLY
(E&I) Educational and Instructional Cooperative Purchasing (STS) State Term Schedule of Ohio
(IUC) Inter-University Council Purchasing Group of Ohio
(NJPA) National Joint Powers Alliance Other
PRODUCT INFORMATION

* Please list your organization's products/services:

CUSTOMER /CLIENT REFERENCES

* ALL THREE NAMES WITH INFORMATION ARE REQUIRED
If possible, provide customer/client names who are higher education institutions:

 
* 1) Name:
* Address:  * City:  * State:  * Zip:
* Phone / ext:  * Fax:  * Email:
* Contact:   * Contact Title:

 
* 2) Name:
* Address:  * City:  * State:  * Zip:
* Phone / ext:  * Fax:  * Email:
* Contact:  * Contact Title:

 
* 3) Name:
* Address:  * City:  * State:  * Zip:
* Phone / ext:  * Fax:  * Email:
* Contact:  * Contact Title: