Vendor Registration Form

Transcription

1 Maricopa County Community College District Purchasing Department 2411 West 14th Street Tempe, AZ Web Site: Voice: (480) Fax: (480) Date: Vendor Registration Form for MCCCD use only Vendor Number: Company Name: Order From Address (This is the name and address that will appear on purchase orders and checks) Division (if applicable): Street / PO Box: City, State, Zip+4: Contact Person/Title: Prompt Payment Discount Terms*: *Use only if the payment terms apply to ALL MCCCD issued purchase orders. Telephone: ( ) FAX: ( ) Remittance Address (if different than Order From Address) Division (if applicable): Street / PO Box: City, State, Zip+4: Contact Person Contact s Title: Telephone: ( ) FAX: ( ) Authorization for Direct Deposit of Supplier Payments (ACH) BANK INFORMATION Name of Bank/Credit Union: Bank/Credit Union Routing Number: Checking Account #*: *Savings Account Numbers May Not Be Used. I hereby authorize: 1) Maricopa Community Colleges to deposit my supplier invoice payment via electronic funds transfer. 2) My financial institution to credit this amount to my account. In the event that the exercise of this authorization for any reason results in an overpayment for supplier invoices actually due and payable to me, I hereby authorize Maricopa Community Colleges to either: A) debit my above-identified account for an amount not to exceed said overpayment, or B) withhold a sum equal to the overpayment from my next disbursement of supplier invoice payment. Page 1 of 7, Revised 04/18/2012

2 Classification Information Class Type (please check one category if applicable): Minority-owned business (MBE) Woman-owned business (WBE) Minority Woman-owned business (MWBE) Tax Information - Required (Please note, a vendor s registration will not be considered by the Maricopa Community Colleges District without the following information.) Tax Reporting Name (Name shown on your income tax return): Taxpayer ID Number: Federal Tax ID #: or Social Security #: Note: The Federal Tax ID # or Social Security # provided must be the correct number for the Tax Reporting Name. Arizona Sales Tax # (transaction privilege tax #) Does your company collect Arizona Sales Tax? Yes No If outside of Arizona, does your company have nexus (presence) with the state of Arizona? Yes No Tax Contact Person: Tax Contact Title: Mailing Address for Tax Forms or Correspondence: Division (if applicable): Street/PO Box: City, State, ZIP+4: Organization Type (Check One): Corporation (includes S-Corp) Individual/Sole Proprietor Partnership Government Agency Limited Liability Company Other **Foreign Suppliers please submit Form W-8 ECI and W-8 BEN available at: Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or person. For federal tax purposes, you are considered a U.S. person if you are 1) an individual who is a U.S. citizen or U.S. resident alien, 2) A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, 3) An estate (other than a foreign estate), or 4) A domestic trust (as defined in Regulations section ). Authorized Printed Name: Authorized Signature: Date: **By completing this form, you are registered with all ten of the Maricopa Community Colleges. To view these campuses, please visit Page 2 of 7, Revised 04/18/2012

3 Commodity Codes of the Maricopa County Community College District Check all of the products and/or services provided by your company A - Advertising B - Automotive Novelties and Advertising Specialty Products, Including Biodegradable Badges, Awards, Emblems, Name Tags And Plates, Jewelry, Etc. Publications, Audiovisual Materials, Books, Textbooks (Prepared Materials Only) Communications And Media Related Services Automotive Accessories For Automobiles, Buses, Trailers, Trucks, Etc. Automotive And Trailer Equipment And Parts Glass and Supplies: Door, Windshield, etc. Automotive And Trailer Bodies, Body Accessories, And Parts Automobiles, School Buses, SUVs, And Vans (Including Diesel, Gasoline, Electric, Hybrid, And All Other Fuel Types) Automotive Shop And Related Equipment And Supplies Fuel, Oil, Grease and Lubricants Tires And Tubes (Incl. Recapped/Retreaded Tires) Equipment Maintenance And Repair Services For Automobiles, Trucks, Trailers, Transit Buses And Other Vehicles C - Buildings and Grounds Air Conditioning, Heating, And Ventilating Equipment, Parts And Accessories Builder's Supplies Buildings And Structures: Fabricated And Prefabricated Office Buildings, Modular and Portable Clothing: Athletic, Casual, Dress, Uniform, Weather And Work Related Electrical Equipment And Supplies (Except Cable And Wire) Fencing Fertilizers And Soil Conditioners Fire Protection Equipment And Supplies Floor Covering, Floor Covering Installation And Removal Equipment, And Supplies Locks, Key Blanks, and Locksmith Tools (Including Time Locks) Janitorial Supplies, General Line Lawn Maintenance Equipment And Accessories Lumber, Siding, And Related Products Material Handling, Conveyors, Storage Equipment And Accessories Painting Equipment And Accessories Plumbing Equipment, Fixtures, And Supplies Road And Highway Building Materials (Asphaltic) Cement, Truckload Lots and Larger (See for Bagged Cement) Roofing Materials And Supplies Signs, Sign Materials, Sign Making Equipment, And Related Supplies Reflective Film (Solar Type Sun Screen) Shade Screens, Louvered or Perforated Venetian Blind Cord and Tape Venetian Blinds, Metal, Audio- Visual and Standard Venetian Blinds, Wood Vertical Blinds, All Types Wind Screens, Privacy Screens, etc Window Shade Cloth Window Shades Water Supply, Groundwater, Sewage Treatment, And Related Equipment (Not For Air Conditioning, Steam Boiler, Or Laboratory Reagent Water) Pest Control (Incl. Termite Inspection and Control, Bird Proofing, Animal Trapping, Rodent Control, Exterminating and Fumigation) Rental Or Lease Of General Equipment (Hvac, Athletic, Fire And Police Protection, Etc.) D - Communications Electrical Cables And Wires (Not Electronic) E - Computers Electronic Equipment, Components, Parts, And Accessories (See Class 730 For Testing Or Analyzing Type) Radio Communication Equipment, Accessories And Supplies Radio Communication And Telecommunication Testing, Measuring, And Analyzing Equipment, Accessories And Supplies Sound Systems, Components, And Accessories: Group Intercom, Music, Public Address, Etc. Television Equipment And Accessories Computer Hardware And Peripherals For Microcomputers Microcomputers, Desktop or Tower based Computer Hardware And Peripherals For Mini And Main Frame Computers Computer Accessories and Supplies Computer Software For Microcomputers (Preprogrammed) Point of Sale Software Computer Software For Mini And Mainframe Computers (Preprogrammed) Equipment Maintenance And Repair Services For Computers, Office, Photographic, And Radio/Television Equipment F - Consulting Services Electrical Accounting/Auditing/Budget Consulting Advertising Consulting Architectural Consulting Communications: Public Relations Consulting Computer Hardware Consulting Computer Software Consulting Construction Consulting Education and Training Consulting Engineering Consulting Environmental Consulting Human Relations Consulting Personnel/Employment Consulting (Human Resources) Legal Consulting Marketing Consulting Medical Consulting Telecommunications Consulting Advisory Services, Educational G - Contractors Security Systems; Intruder and Smoke Detection - Architectural Paving/Resurfacing, Alley and Parking Lot Construction Services, Trade (New Construction) Concrete Electrical Heating, Ventilating and Air Conditioning (HVAC) Masonry Painting and Wallpapering Plumbing Roofing And Siding H - Food Services Cafeteria And Kitchen Equipment, Commercial Foods: Bakery Products (Fresh) Foods: Dairy Products (Fresh) Foods, Frozen Page 3 of 7, Revised 4/18/12

4 I Furniture Foods: Perishable Foods: Staple Grocery And Grocer's Miscellaneous Items Soft Drinks Furniture: Health Care, Hospital And/Or Doctor's Office Furniture: Laboratory Furniture: Cafeteria, Chapel, Dormitory, Household, Library, Lounge, School Auditorium, Stadium, Team Seating Furniture and Portable Bleachers Children's Furniture (Incl. Stackable Types) Furniture: Office J - Instructional & Library Products Art Equipment and Supplies Crafts, Specialized Library And Archival Equipment, Machines, And Supplies Machinery and Hardware, Industrial Musical Instruments, Accessories, and Supplies Photographic Equipment, Film, And Supplies (Not Graphic Arts, Microfilm, And X-Ray) Police and Prison Equipment and Supplies School Equipment, Teaching Aids, And Supplies Atlases, Charts, Globes, and Maps Books: Class Register, Record, and Plan Books Instructional Aids: Courses, Lesson Plans (Prepared), Programs, Ancillary Materials, Videos, etc Vocational Equipment and Supplies Sporting Goods, Athletic Equipment And Athletic Facility Equipment Theatrical Equipment and Supplies Visual Education Equipment and Supplies Audio Visual Equipment and Supplies Welding Equipment and Supplies Bookbinding And Repairing Services K - Laboratory/Medical Equipment and Supplies Chemical Laboratory Equipment And Supplies Clinical Laboratory Reagents And Tests (Blood Grouping, Diagnostic, Drug Monitoring, Etc.) Dental Equipment and Supplies Cardiovascular Instrumentation: Defibrillators, Heart Pumps, Monitoring Equipment, etc Laboratory Equipment, Accessories And Supplies: General Analytical And Research For Nuclear, Optical, And Physical Mass Spectrometers and Accessories Microscopes, All Types L - Office Equipment & Supplies Forms, Continuous: Computer Paper, Form Labels, Snap-Out Forms, And Folders For Forms Office Machines, Equipment, And Accessories Copy Machines, Bond (Plain) Paper Type Including Parts and Accessories Office Supplies: Carbon Paper And Ribbons, All Types Office Supplies, General Stock Forms and Labels: Copy Sets, Receiving Forms, Speed Letters, etc Office Supplies: Erasers, Inks, Leads, Pens, Pencils, Etc Paper, For Office And Print Shop Use M - Printing Products & Services Printing Plant Equipment And Supplies (Except Paper) N - Services Graphic Arts Services (Not Printing) Mailing Services (Includes, Addressing, Collating, Packaging, Sorting and Delivery) Printing And Typesetting Services Copying Services (Reproduction) Paper Cutting, Drilling, Folding, Punching, Shredding, Trimming, etc. Musical Instrument Repair Parts and Supplies (Except Organ and Piano) Architect Services, Professional Graphic Design - Architectural Landscape Architecture Building Construction Services, New (Incl. Maintenance And Repair Services) Site Work (Incl. Site Clean-Up) Carpet Cleaning, Dyeing, Installation and Repair Chimney Installation, Maintenance and Repair Elevator Installation, Maintenance and Repair Garbage/Trash Removal, Disposal and/or Treatment Heating, Air Conditioning, and Ventilation Maintenance and Repair Services (Including Installation) Janitorial/Custodial Services Locksmith Services Painting, Maintenance and Repair Services (Including Caulking) Pest Control (Incl. Termite Inspection and Control, Bird Proofing, Animal Trapping, Rodent Control, Exterminating and Fumigation) Excavation Services Paving/Resurfacing, Alley and Parking Lot Cable Television Services (Includes Pay-Per-View Services) Media Clippings, Outtakes, Critiques, Summaries, Legislative Bill Tracking Services, etc. (Incl. State, Local, Out-of-State and International) Photography (Not Including Aerial Photography) Telephone Services, Cellular Telephone Services, Long Distance and Local (Including 800, Telex, Watts Services, and Offender Telephone Systems) Video Production Web Page Design, Management and Maintenance Services Networking Services (Including Installation, Security, and Maintenance) Educational/Training Services Examination and Testing Partnering Workshop Facilitation Services Air Conditioning, Heating and Ventilating Engineering Civil Engineering Electrical Engineering (Incl. Cogeneration Design Services) Environmental Engineering Geotechnical Engineering Mechanical Engineering Structural Engineering Recycling Services Financial Services Appraisal Services, Real Estate Appraisal Services (Not Otherwise Classified) Banking Services Collection Services, Financial Debt Financial Advisor Installment Purchase/Lease Purchase Financing and Lease With Option to Purchase Financing Health Related Services Insurance And Insurance Services, (All Types) Laundry And Dry Cleaning Services Laundry and Linen Service Page 4 of 7, Revised 04/18/2012

5 Library Services (Incl. Research And Subscription Services) Business Research Services Cataloging Services Historical Studies and Services Internet Database Subscriptions Library Services (Not Otherwise Classified) Magazine Subscriptions Newsletter Subscriptions Newspaper Subscriptions Professional Document and Publication Subscriptions (Legal, Medical, etc.) Professional Journal Subscriptions Research Services (Other Than Business) Scientific Research Services Talking Books, Cassettes, etc. (For the Vision Impaired) Training Material Subscriptions Concessions, Catering, Vending: Mobile and Stationary Food Management Services Records Management Services Floral Designing and Arranging Services Floral Designing and Arranging Services Interpreter Services (Foreign Language, Hearing Impaired etc.) non-electronic Marketing Services (Incl. Distribution, Research, Sales Promotions, etc.) Theatrical Services (Including Production, Scenery Design Stage, etc.) Travel Agency Services Utility Services, Electric Auctioneering Services (To include Internet Type) Courier/Delivery Services (Including Air Courier Services) Hazardous Material and Waste Services (Including Emergency Response and Nuclear Wastes) Installation and Removal Services (Not Otherwise Classified) Moving Services Professional Services (Not Otherwise Classified) Travel, Local (Provided by Third Party) Travel, Non-Local (Scheduled and Unscheduled), Provide by Third Party (Incl. Commercial Airplane Travel and Helicopter Services) Personnel Services, Temporary Silk Screen Printing Public Works And Related Services Street Sweeping Services Vehicle Towing And Storage Real Property Rental or Lease O. - Miscellaneous Other Building, Fabricated, Pre-Fabricated or Premanufactured, Rental or Lease Hotel/Motel Accommodations (Incl. Lodges, Resorts, Bed/Breakfast Inns, etc.) Rental or Lease Land, Rental or Lease Office Space Rental or Lease Room Rental or Lease for Conferences, Seminars, etc. Film, Movie and Video Tape Rental or Lease Landscaping (Including Design, Fertilizing, Planting, etc., But Not Grounds Maintenance or Tree Trimming Services Tree Trimming And Pruning Services Security, Fire, Safety, And Emergency Services (Including Disaster Document Recovery) Guard And Security Services Aircraft And Airport Equipment, Parts, And Supplies Clothing: Athletic, Casual, Dress, Uniform, Weather And Work Related Appliances And Equipment, Household Type Studio Equipment: Furnishings, Record and Tape Storage Cabinets, Tables, etc. Equipment Maintenance And Repair Services For Appliance, Athletic, Cafeteria, Furniture, Musical Instruments, And Sewing Equipment Equipment Maintenance And Repair Services Donations Meals Membership Dues Registration Fees Sponsorships (All Types) Warranties Photographic and Recording Facility Rental or Lease Rental Or Lease Services Of Appliances, Cafeteria, Film, Furniture, Hardware, Musical, Sewing, And Window And Floor Coverings Rental Or Lease Services Of Office, Photographic, Printing, Radio/Television/Telephone Equipment Page 5 of 7, Revised 4/18/12

6 Instructions for Completing the Vendor Registration Form: 1. Make a copy of the blank registration form to notify us of address changes your company may have in the future. 2. Type this form, if possible. This form can be filled out online at 3. Make sure the form is signed. 4. Enter the purchasing site address in the first block. 5. Enter the remittance address; the address MCCCD will send payment to in the second block. Include payment terms only if it relates to all MCCCD issued purchase orders. If you wish to receive electronic payments, please check the check box. 6. Check a classification type in third block, if applicable; otherwise, leave the block blank. 7. A Federal Tax ID number or a Social Security number must be included on this form in order to be listed as a vendor with MCCCD. If a Social Security number is listed, please indicate the legal name for that number. Your parent company or headquarters may have a different Federal Tax ID number from yours. Please enter your Federal Tax ID number. The District is NOT exempt from sales tax (except for Library use) and pays sales tax to in-state vendors. For purchases from out-of-state vendors who do not have an Arizona Transaction Privilege Tax License, the District pays use tax to the State of Arizona. If your company does not have an Arizona Transaction Privilege Tax License, mark none in the appropriate box. 8. If you are a foreign individual or foreign corporation use form W-8 ECI or W-8 BEN. These forms are available to be downloaded from the Web at 9. The second and third page lists commodity categories. Please indicate the commodity category or categories your business falls under. If your product or service is not listed, please list your product or service on the line marked Other. For bid opportunities, please check our Web site at on a regular basis. 10. If you prefer to receive electronic payments, 11. Send your completed vendor registration form to: Maricopa County Community Colleges District Office, Purchasing Department 2411 West 14th Street, Tempe, AZ Questions? Please call us at (480) Page 6 of 7, Revised 04/18/2012

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