Company Name

Company Email

Website

Phone

Fax

Federal ID or SSN

Parent Company

New Application
Update

Individual
Partnership
Corporation
LLC (Limited Liability Corporation)

Where bidding forms and purchase orders are to be mailed

Address

 

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Where payments are to be mailed (If different from mailing address)

Address

 

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Persons to contact and those authorized to sign bids and contracts in your name (if agent, please specify)

Name

Job Title

Email

Phone

Cellphone

Name

Job Title

Email

Phone

Cellphone

Do you require a hard copy of verbal orders? 

Yes  
No  

Do you accept Procurement Cards?   

Yes
No

Do you have a website that provides catalog information and online ordering?

Electronic Catalog

Electronic Ordering

Please Complete The Following:

Standard Payment Terms

Prompt Pay Discount

Standard Delivery Time

Please List Percentage And Circle Category That Applies:

Women Ownership

%

Minority Ownership

%

African American
American Indian/Alaskan Native
Asian
Hispanic

Disabled Ownership

%

Are you a Small Business?

Yes
No

Are you located within the GRCC District?

Yes
No

 Are You Certified? If So, list the Agencies and Certificate Numbers

Please check the appropriate code and provide a detailed description of the commodities and/or services offered.  If the complete NAICS Code is known please include this number in the description area.

More information is available on the NAICS website

Check below the category which applies to the applicant

Manufacturer or Producer
Wholesaler
Retailer
Manufacturer's Agent
Distributor
Service Establishment