SUPPLIER APPLICATION FORM by mallorycarlson

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									                 SUPPLIER APPLICATION FORM

April 30, 2008


Thank you for your interest in doing business with the City of Corona. We ask
that you take the time to complete the attached Supplier Application Form so we
can include your company in our supplier database. While the City recognizes
your time and literature as a very valuable resource, we can make no guarantees
that your company will be contacted for every purchasing need. Current bidding
opportunities are available on our website at www.discovercorona.com


Please mail your completed form along with any additional information regarding
your firm to:

                             City of Corona
                             Purchasing Division
                             400 S. Vicentia Avenue
                             Suite 320
                             Corona, CA 92882


If you have any questions, please contact the Purchasing Office at (951) 736-2272
or e-mail purchasing@ci.corona.ca.us. The fax number is (951) 736-2445.


Sincerely,

CITY OF CORONA
Purchasing Division
                                            SUPPLIER APPLICATION FORM
                                                             CITY OF CORONA
SUPPLIER OF GOODS OR SERVICES ONLY To be completed by ALL FIRMS OR INDIVIDUALS PROPOSING TO DO BUSINESS WITH
THE CITY OF CORONA (regardless of commodity, service, or product offered)
COMPANY NAME:                                                                  CONTACT NAME:


STREET/CITY/ZIP


MAILING ADDRESS: (if different from street address)


TELEPHONE NO: (             )                             TOLL FREE NO: (          )                           FAX NO: (            )

WEB SITE ADDRESS:                                                               E-MAIL:
Are any of the owners or owners’ relatives currently employed by the City of Corona                          YES                    NO
If yes, please provide details on an attached sheet of paper.
FEDERAL I.D. NO./SOCIAL SECURITY NO.                        DUN & BRADSTREET NO.                            CITY OF CORONA BUSINESS LICENSE NO.


PRIMARY TYPE              BROKER              DEALER           DISTRIBUTOR                                FABRICATOR                MANUFACTURER
OF BUSINESS:              MANUFACTURERS AGENT        RETAIL/SERVICE                                 WHOLESALER                  OTHER _______________

PRINCIPAL OWNERS:                         Name                                                         Title                              Percent Ownership
                                                                                                                                                         %
                                                                                                                                                         %
THIS IS A PARENT COMPANY: (Name of subsidiaries)                              THIS IS A SUBSIDIARY: (Name and location of parent company)

NUMBER OF YEARS IN           AVERAGE ANNUAL SALES            NET WORTH OF         NORMAL INVENTORY                 APPROXIMATE SIZE OF             NUMBER OF
    BUSINESS                    (PRIOR 3 YEARS)                BUSINESS                VALUE                         FACILITIES (sq. ft.)          EMPLOYEES



DESCRIPTION OF PRODUCTS & SERVICES (required field):




TYPE OF BUSINESS ENTITY                                   CALIFORNIA LICENSE CLASSIFICATION


CUSTOMER REFRENCES:             Contact                                   Phone Number                                           E-mail address
1)
2)
PERSON(S) AUTHORIZED TO COMMIT YOUR FIRM TO A CONTRACT:
Name                                              Title                        Name                                Title
Name                                              Title                        Name                                Title
Owner Status-Business is at least 51% Owned, Controlled, and Actively Managed by (check all business categories that apply):

 □   LBE             □ SBE                □ DBE             □ WBE               □ DVBE
Ownership Status Categories: (Place an "X" in the boxes that best describe your firm's ownership)
Type of Business                      Asian/Indian     Black                     Native          White                                             Socially &
                                      Asian/Pacific    African     Hispanic     American        Caucasian                      Disabled           Economically
                                       American       American     American      Indian         American        Other          Veteran            Disadvantaged
LARGE              Woman Owned
BUSINESS
                   Male Owned
SMALL              Woman Owned
BUSINESS
                   Male Owned


INSURANCE:                Is your Company Insured?                  YES                    NO


Name of Insurance Company for General Liability:                 ____________________________________________________


Name of Insurance Company for Automobile Liability:              ____________________________________________________


Name of Insurance Company for Workers Compensation: ____________________________________________________
For services performed “on-site”, the City of Corona requires a minimum of $1 million for insurance limits with endorsements
listing the City as additional insured. Limits may be higher based on degree of risk. All insurance must be AM Best Rated A,VIII
and insured in the State of California. All insurance policies required shall be subject to review and approval by the City of
Corona.
SIF.wp.swb.12/13/2007

								
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