University Of Alaska Statewide Procurement Office PO Box 755100 Fairbanks, Alaska 99775-5100 Bidder Application Form Commodities and Contractual Services Please print Company Name: Mailing Address: City: State: Postal Code: - Contact Person: Telephone Number: ( ) Facsimile Number: ( ) Alaska Business License Number: Exp. Date: 1999 You must submit a clear/legible copy of your business license or provide other license veri fication. See page 1 of bidder packet. Contractor License Number (if applicable): Exp. Date: 1999 You must submit a clear/legible copy of your contractor’s license or provide other license verification. See page 2 of bidde r packet. Small and Disadvantaged Business Information The University of Alaska offers and equal opportunity to small and disadvantaged business concerns. As a recipient of federa l funds, it is necessary that information concerning size status of eligible firms be placed on the consolidated bidders mailing list. To this end, it is requested that you check the appropriate boxes below that describe your business. 1. Is the firm at least 51 percent owned and controlled by U.S. citizens who are: Black Americans Hispanic Americans Asian-Pacific American Includes U.S. citizens whose origins are in Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U.S. Trust Territory of the Pacific Islands, the Northern Mariana Islands, Laos, Cambodia or Taiwan. Asian-Indian Americans Includes U.S. citizens whose origins are in India, Pakistan or Bangladesh. Native Americans Includes U.S. citizens whose origins are American Indian, Alaskan Indian, Aleut, Eskimo or Hawaiian. 2. Is the firm at least 51 percent woman-owned and controlled? Yes No 3. Size Standard Information: Average number of employees (including affiliates) for four (4) preceding calendar quarters: Average annual sales or receipts for preceding three (3) fiscal years: Updated 07/28/10 Commodity/Contractual Service Codes Refer to bidder application packet for code listings. Remember only list codes that your company is consistently capable of bidding on. Example: 7 0 0 0 3 Printed Name: Signature: Date: Did you remember to… complete both sides of the form? enclose a copy of you licenses or acceptable verification? sign the form? Send completed form with license verification to the address listed on the front of this form . .
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