Vendor Information Form

1. Mailing Address For bid specs, orders, contracts, etc.
2. City
3. State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
4. Zip

1. Payment Address If different from Mailing Address
2. City
3. State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
4. Zip

1. Certified Minority Business Enterprise (MBE)
2. Certified Female Business Enterprise (FBE)
3. Certified Persons with Disabilities Business Enterprise (PBE)
4. Certified Small Business Enterprise (SBE)
5. Certified Veteran-Owned Business (VOB)
6. Sheltered Workshops (SWS)

1. African American
2. Hispanic
3. Asian
4. American Indian
5. Other
   Other Ethnicity

1. Tax Structure

   1. Corporation
   2. Sole Proprietorship
   3. Limited Liability Company (LLC)
   4. Partnership
   5. Other
      Other Tax Structure
2. Tax Reporting Name

You are required to submit a completed W-9 with this application.

Check each box and sign application (your typed name serves as your signature).

1. Vendor Terms

   1. All purchasing must follow the laws of the State of Illinois and the Illinois Public Community College Act as well as Board Policy of Sauk Valley Community College.
   2. I hereby certify that the information supplied herein is correct. I understand that misrepresentation may be cause for removal from the qualified vendor list and any other penalties allowed by law.
   3. If any of the vendor information on this form changes, the vendor must complete a new form indicating “Existing Vendor Information Update.”
2. Signature
3. Title