Spreadsheet: 9de805ca-c3aa-4469-9881-000e4cbb36eb
Sheet: Sheet1

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TO: | PURCHASING OFFICE - 1200 NORTH UNIVERSITY DRIVE, MAIL SLOT 4979
 | PINE BLUFF, AR, 71601 |  |  |  |  |  | Today's Date:
1. | Name of Applicant or Business |  |  |  |  |  | Phone No.
 | Mandatory: Tax ID#
2. | Address to which bid invitations are to be mailed:
 | [NAME]
 | Street Address:
 | City & State
3. | Home Office Address:
4. | How long in present businesss:
 | If in business less than two years, see item 26.
5. | Number of Employees:
 | Number of Employees in Arkansas:
6. | Type of organization:
 | Individual |  | Partnership |  | Corporation
7. | If incorporated, when and in which state?
8. | Applicant is a:
 | Manufacturer |  | [NAME] |  | Wholesaler |  | Retailer
 | Manufacturer's Representative: |  |  |  |  | Service Establisher:
9. | Arkansas Sales or Use Tax Number:
10. | State Employers insurance Identification Number:
 | Which State:
11. | In which Arkansas counties do you pay real and/or personal property taxes?
 | (must be paid in your business name.)
12. | Names of officers, members, or owners of business:
 | (A.) President
 | (B). Vice President
 | (C). Secretary
 | (D). Treasurer:
 | (E). Owner(s)
13. | Signature and name of persons authorized to sign bids. (Must be manually signed) This listing must
 | be kept current.
 | SIGNATURE |  |  | NAME |  |  | TITLE |  | PHONE
14. | Net worth of Application:
 | Amount |  |  | as of (date) |  |  | Commercial rating?
 | Copies of financial statements must be made available if requested.
15. | Bank reference(s)?
16. | Approximate inventory normally stocked.
17. | Where is your principal factory/business located?
18. | References (customers) other states or governmental units:
 | NAME |  |  | ADDRESS |  |  |  |  | BUSINESS
19. | Have you sold to the State of Arkansas? |  |  |  |  | When?
20. | Has any state agency filed a complaint against you or your merchandise or service? |  |  |  |  |  |  |  | If so, list
 | dates:
21. | Has a performance penalty ever been assessed against you?
 | When?
22. | Are your products manufactured in Arkansas?
 | Yes |  | No |  | If not, in which State
23. | Previous business address?
 | Years
24. | Previous firm name?
25. | Principal line of business?
26. | If your company has been in business less than two years we will need additional information establishing
 | further qualifications of your company. We will be glad to receive information that would show affiliations
 | with other companies and/or your personnel that would add knowledge of your respective business field.
 | This may be in the form of a letter or listed under Bidder's Comments below.
27. | Affiliated Concerns (names, location and in detail, controlling interest in each)
28. | Indicate here the commodity classes on which you wish to bid. |  |  |  |  |  | (Commodity Listing)
 | CODE |  | CODE |  | CODE |  | CODE
BIDDER'S COMMENTS:
29. | Is the company: (check one)
 | Minority |  | Small Business
30. | I, the undersigned, hereby certify that the above and foregoing information is a full, true, and correct
 | statement of the facts. I agree to faithfully abide by the purchasing laws of the State of Arkansas and
 | regulations of the Department of Finance and Administration now in effect and any subsequent revisions
 | there-of. I also understand and agree that my failure to submit either a bid or a no bid response on three (3)
 | consecutive bid invitations on any one class could cause the Office of Procurement (UAPB) to discontinue
 | sending me bid invitations on that particular class.
 | Signature:
 | Name: (typed or printed):
 | Title: (typed or printed):
 | Date:
This form should not be faxed, it must be mailed to:
 |  |  |  |  | University of Arkansas at Pine Bluff
 |  |  |  |  | Office of Procurement
 |  |  |  |  | Mail Slot 4979
 |  |  |  |  | Pine Bluff, Arkansas 71601
This form must also reflect "original" signature, not copies.
PLEASE READ:
02/2000
The Office of Procurement takes no responsibility if you are dropped from the bidder's list due to non-responsiveness
to solicitations for bids. You must mail in the response even if it is a "no bid." We apologize if you do not receive
an invitation due to human error. All of our formal bids are advertised in the Arkansas Democrat [NAME]. We
encourage you to check in with us on a frequent basis and thank you for your interest in the University of Arkansas
at Pine Bluff.
The Director of Materials Management (Procurement) C.P.P.B.