E-Gov Services City of Maricopa

VENDOR REGISTRATION

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PURPOSE. THIS FORM IS USED TO COMMUNICATE WITH CITY PERSONNEL TO REQUEST SERVICES AND INFORMATION.

* Information is required.

Contact Information

First Name:
Last Name:
Email:
Daytime Phone:	() –
Fax:	() –
Address:
City:
State:
ZIP:

* COMPANY NAME:

* DBA (AS APPLICABLE)

* COMPANY ADDRESS

* FEDERAL EMPLOYER IDENTIFICATION NUMBER (or SSN)

SECONDARY CONTACT NAME:

SECONDARY CONTACT PHONE NUMBER:

SECONDARY CONTACT CELL PHONE NUMBER:

SECONDARY CONTACT FAX NUMBER:

SECONDARY CONTACT EMAIL ADDRESS:

* PRODUCT/SERVICE COMMODITY PROVIDED1
Please view the Commodity Codes Document for Listing

PRODUCT/SERVICE COMMODITY PROVIDED2
Please view the Commodity Codes Document for Listing

PRODUCT/SERVICE COMMODITY PROVIDED3
Please view the Commodity Codes Document for Listing

* CITY OF MARICOPA BUSINESS LICENSE:

* IF YES, GIVE NUMBER

* CURRENT GOVERNMENT CONTRACTS AWARDED TO YOUR BUSINESS (PLEASE LIST NAME AND CONTACT NUMBER) STATE, MUNICIPAL, WSCA, MOHAVE, US COMMUNITIES, OTHER

* THE FOLLOWING BUSINESS OWNERSHIP CLASSIFICATIONS ARE APPLICABLE: DISADVANTAGED BUSINESS ENTERPRISE OWNERSHIP CLASSIFICATION

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