Supplier Application Form

Please complete and submit the following information. Items marked with an asterisk (*) are required.

General Information

* Full Legal Business Name:
Doing Business As:

Business Address (mailing address)

* Street:
Street Line 2:
* City: * State/Province: * Postal Code:
* Country:


* Remittance Address (where to pay bill)
 Same as above

Street:
Street Line 2:
City: State/Province: Postal Code:
Country:


* Physical Location
 Same as above

Street:
Street Line 2:
City: State/Province: Postal Code:
Country:


Contact Person

* Contact Name:
* Official Position:

Address Line 1:
Address Line 2:
Address Line 3:
City:
State/Province:       Postal Code:  
Country:

* Contact Phone:        Country Code | Area Code | Phone # | Extension
* Contact E-mail:
* Contact Fax Number:        Country Code | Area Code | Fax # | Extension

Business Phone:        Country Code | Area Code | Phone # | Extension
Business Website:


Business Organization

* Please select one:
Corporation If so, incorporated in (State/Province): Date Incorporated: (mm/dd/yyyy)
Partnership
Sole Proprietor
Other (Please specify)  

Federal Identification Numbers:

FEIN:    Please do not enter social security numbers.
DUNS Number:  
Austin Tetra (AT) Number:    Don't have an AT number? Click here!

* Business Profile (check all that apply):

Construction Concern
Dealer with Inventory Stock
Dealer without Inventory Stock
Distributor
Manufacturer/Producer
Professionally Licensed
Service Establishment
Other   (Please specify) 

Primary NAICS Code: 
(6 digit code listing may be accessed here, please use the search box located in the upper left corner)

 * Number of years in business: 

* Is your business a branch or subsidiary of another firm?  Yes    No
If yes, please specify parent company: 

* Estimated gross receipts/sales last year: 

* Number of employees:
Company Wide: 
At this location: 
In Pennsylvania: 

Select the types of equipment, supplies, material, and/or services you wish to bid on and sell:
Advertising
Agricultural Items
Air Compressors
Air Conditioning
Animals & Feed
Appliances, Household
Architecture, Interior Design and Engineering
Arts & Crafts
Asbestos Abatement
Athletics
Audio-Visual
Automotive Parts
Bedding
Biomedical
Blinds
Books
Boxes
Building Maintenance
Building Material
Building/Structure Leases
Bus Charters
Carpet
Catering
Chemicals
Clothing
Coal
Compressors
Computers, Hardware
Construction
Consulting Agreements
Copiers
Cryogenics
Cylinder Gas
Document (Shredding & Storage)
Drafting
Drapery
Dry Ice
Electrical Supplies
Electronics
Elevators
Engineering
Envelopes
Environmental Testing
Facsimile
Farming Equipment
Fire Extinguishers
Food (non-catered)
Food Equipment
Form, Business
Fuel
Furniture
Glassware, Laboratory
Hardware, Building
Hazmat Disposal & Monitoring
Heating
Industrial Supplies
IT Services
Janitorial
Lab Coats
Landscaping Equipment
Linens
Lockers
Lubricants
Lumber
Marketing
Material Handling
Medical
Metal/Steelwork
Microfilm
Moving & Storage
Musical Instruments
Novelties
Office Equipment & Supplies
Oil & Gas
Paint
Paper, Janitorial
Paper, Printing/Writing
Pharmaceuticals
Photographic
Plumbing
Pneumatic/Hydraulics
Power Transmission
Printed Material
Printers
Printing
Propane
Refrigeration
Safety Equipment
Scientific
Security Systems
Software, Licensed & Standard
Storage Tanks
Telecommunications
Transportation
Trash Removal
Uniforms
Utilities, Electric, Water and Natural Gas
Vehicles, Purchases, Rentals and Repair
Videos, Duplication, Pre-recorded and Production
Wall Covering
Water Treatment
Welding
Workshops/Training
Other (Please specify) 

List the manufacturers or brand names your business distributes or produces:


Business Status (In accordance with Federal and Pennsylvania Guidelines)
(Questions on business size/type should be referred to the Federal Small Business Administration at 1-800-U-ASK-SBA or refer to SBA website at www.sba.gov)

* Business Classifications (check all that apply):

Large Business
Small Business
Small Disadvantaged Business (SDB)
Minority Owned Business Enterprise (MBE)
Woman-owned Business Enterprise (WBE)
HUB (Historically Underutilized Business) Zone
Service Disabled Veteran-Owned Small Business
Veteran Owned Small Business
Alaska Native Corporations (ANCs) and Indian Tribes (that are not Small Businesses)
Alaska Native Corporations (ANCs) and Indian Tribes (that have not been certified by the Small Business Administration as Small Disadvantaged Businesses)

Are the classifications selected above certified by the Federal Government Small Business Administration?    Yes    No
Are the classifications selected above certified by the State of PA Department of General Services?    Yes    No

The following response is optional:
LGBT Owned Enterprise (Lesbian Gay Bisexual Transgender Business Enterprise)
Is the LGBTBE classification selected above certified by the National Gay and Lesbian Chamber of Commerce?     Yes    No


Certification (check all that apply):

Suspended (Please explain) 
Debarred     (Please explain) 


Please identify if you have any contracts with the following:

Contract Number Web Link
GSA Contract:     
Commonwealth of PA (DGS):
E & I Cooperative:
Other:
Other Description:


*Terms:

       *Payment
         Discount (%)   Days:  Net:  (e.g. 10%, 20 Days, Net 30)

       *F.O.B.
         Destination
         Destination/Prepay
         Other (please specify)  


* Conflict of Interest Statement

Does any Penn State employee serve as an officer or director of this company?  Yes
No

Is any Penn State employee a partner or sole proprietor of this company?  Yes
No

Is any immediate family member (spouse or dependent child) of a Penn State employee a partner or sole proprieter of this company?  Yes
No

Does any member of a Penn State employee's immediate family (spouse or dependent child) have an ownership interest of 10% or more in this company?  Yes
No

Does any Penn State employee hold any paid position in this company?  Yes
No

Does any Penn State Board of Trustee serve as an officer or director of this company?  Yes
No

Does any member of a Penn State Board of Trustee's immediate family (spouse or dependent child) have an ownership interest of 10% or more in this company?  Yes
No


If you answered yes to any of the questions in the "Conflict of Interest Statement", please identify the pertinent individual(s) and their relationship to this company:


* Information completed by:

* Name:
* Position:
* Phone:
* E-mail:
* Date:

 


Effective: 2/22/2007


Penn State Auxiliary and Business Services

Questions about Purchasing Supplier Application, contact:
Purchasing Services at 814-865-7561 or purchasing@psu.edu.

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Information Systems Office for Auxiliary and Business Services ( ABSsupport@psu.edu ).

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This page was last updated on 04/03/2017 at 1:38 PM