STARS New Supplier/Vendor Entry Request Form

Transcription

1 STARS New Supplier/Vendor Entry Request Form Vendors are to complete this form and it to the Purchasing Office to the attention of Your Requester Name: Dept./School: Phone Number: Fax: Address: All this information is REQUIRED for processing Vendor Name: Street Address: City/State: Zip Code: Phone: FAX: Payment Address (if different from above): address where purchase orders should be sent: Tax ID Number: WEBSITE: Vendor's Virginia Contractor's License Number (if applicable): Class: UPDATED 4/15 Does the Vendor have any pending actions against its Contractor s license? (if applicable): Yes: No 1

2 If yes, provide details. Virginia State Corporation Commission (SCC) Identification Number: Contact the SCC at or the Clerk s Office at (804) for more information. Tax ID # or (Soc. Sec.#. If Sole Proprietor) Arlington Business License Number: Type of Business Small Business Women Owned Business Minority Owner Business Service Disabled Owned Business Employment Service Organization None of the above Organization Indicate if: Corporation Sole Proprietor Partnership Joint Venture Other (Indicate) How many years has the vendor been in business? How many years has the vendor been in business under its present business name? Provide previous names (s) of the vendor within the last eight (8) years, if applicable. 2

3 If vendor is a corporation, please indicate: Date of incorporation: State of incorporation: President's name: Vice President's name(s) Secretary's name: Treasurer's name: If vendor is a partnership, please indicate: Date of organization: Type of partnership (if applicable): Name(s) of general partners: If vendor is a sole proprietorship, please indicate: Date of organization: Name of owner: If the form of the Vendor is other than those listed above, describe it and name the principals: Is the vendor related to another firm as a parent, subsidiary or affiliate? Yes No 3

4 If yes, give names and addresses of all affiliated parent and/or subsidiary companies. Indicate which companies are subsidiaries. Judgments Has the vendor or any officer, director or owner thereof had any judgments entered against him within the past ten (10) years for breach of contracts? Yes No If yes, provide details on any such judgment. Contract Compliance Has the vendor been found to be in substantial noncompliance with the terms and conditions of prior contracts with any public body without good cause? YES NO If yes, provide details on any such instance. Convictions Has the vendor or any officer, director, owner, project manager, procurement manager or chief financial officer thereof been convicted within the past ten (10) years of a crime related to governmental or non-governmental contracting, including but not limited to, a violation of: (i) Article 6 ( et seq.) of Chapter 43, Title 2.2 of the Virginia Public Procurement Act, (ii) the Virginia Governmental Frauds Act ( et seq.), Chapter 4.2 (59.1, (iii) Chapter 4.2 ( et seq.) of Title 59.1, or (iv) any substantially similar law of the United States or another state; Yes No If yes, provide details. 4

5 Debarment Is the vendor or any officer, director or owner thereof currently debarred pursuant to an established debarment procedure from bidding or contracting by any public body, agency of another state or agency of the federal government? Yes No If yes, provide details. Completed by: Contact Person: Address: Office Telephone Number: Cell Phone Number: Typed/Printed Name: Signature: Date: All fields are required to be completed before a vendor can be added into STARS. Arlington Public Schools Purchase Order Terms and Conditions can be found at Please send this completed form via to thanh.thai@apsva.us. Be sure to include the completed W-9 Tax form and Criminal Conviction form. NOTE: Purchase Orders are ed from Arlington Public Schools' enterprise planning resource system. ( If you desire.) Please add wfpacp2i@atoracle.com to your list of known/safe addresses. 5

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7 Attachment A CONTRACTOR CERTIFICATION REGARDING CRIMINAL CONVICTIONS This form must be completed by an authorized official for any organization contracting to provide services under a contract with the Arlington Public Schools or any of its schools or departments, or any subcontractor under such contractor. The completed form from the Contractor is a condition precedent to the award of the Contract. As the official authorized to enter into this Contract on behalf of my organization, I certify that: 1. No employee of the organization who will be in direct contact with students on school property during regular school hours or during school-sponsored activities during the performance of this Contract has been convicted of a felony or of any offense involving the sexual molestation, physical or sexual abuse or rape of a child; and 2. As more particularly set forth in Virginia Code Ann. Section , no employee who has been convicted of rape, forcible sodomy or object sexual penetration, all of a child under 13, during the commission of abduction, in the course of entering a dwelling with intent to commit murder, rape, robbery, arson, larceny, assault and battery, or any felony, or of aggravated malicious wounding will enter upon the property of an existing elementary or secondary school in the performance of the Work; and 3. As more particularly set forth in Virginia Code Ann. Section , no employee who has been convicted of a sexually violent crime shall enter upon the property of any existing elementary or secondary school during school hours or during school-related or school sponsored activities in the performance of the Work. I understand that a materially false statement regarding this certification is a Class 1 misdemeanor and that conviction of such misdemeanor shall result in the revocation of this Contract and of any related license that I may hold. I declare under penalty of perjury that the foregoing statements are true and correct. Name of Firm Address of Firm Telephone Signature Name and Title (please type or print) Date UPDATED 4/15 7

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