Form Center

Section 1

Date Submitted*
Date Submitted
Vendor # ____________________
(For County Use Only)
Company Name*
Legal Vendor/Company Name
Business Name
Doing Business As, If Different From Above
Address1*
Address2
City*
State*
Zip*
First Name*
Contact Name
Last Name*
Email Address*
Contact Email
Phone Number*
Contact Phone
Fax Number*
Contact Fax Number
Tax Payer ID (TIN)*
Federal EIN or Social Security Number
Web Address
Type of Business*
Select One
1099 Category
Specify 1099 Category If Known
Business Certified As:
Please mark all that apply:
1. HUB - Historically Underutilized Business
2. MBE - Minority Business Enterprise
3. SBC/SBE - Small Business Concern
4. SDB/DBE - Small Disadvantaged Business Concern
1. WBC - Women Owned Small Business Concern
2. WBE - Women Owned Business Enterprise
3. HSBC - Hub Zone Small Business Concerns
4. SCVO - Small Disadvantaged Veterans Owned
Certifications:
Please indicate if your company is certified by one or more of the following councils / agencies:
1. ISO
2. CCR - Federal/State/Municipal
1. FSC
2. SFI
1. PEFC
2. C-TPAT
Category*
1. Bridges
2. Chemicals
3. Financial
4. Food Services
5. Fuels
6. Healthcare Services
7. Maintenance
8. Office Products
9. Printing
10. Road & Highway
11. Salt
12. Services
13. Technology
14. Utilities/ Utility Consultants
Please pick a category.
Products*
List Principal Products and/or services offered by your company.
Green Initiatives
Describe any sustainability or green initiatives your company is involved in. Does your company use any Green E or Green Seal products? If so, please list.
Continue

Section 2

A valid County Purchase Order Number and/or Purchase Order must be received by vendor PRIOR to commencing production or services and must be referenced by number on your company’s invoice.
The following information is requested for the expediting purchase orders or pricing information.
Please enter the purchase order or pricing address if different from above.
Address1
Address2
City
State
Zip
First Name
Contact Name
Last Name
Email Address
Contact Email
Phone Number
Contact Phone Number
Fax Number
Contact Fax Number
Continue |Go Back

Section 3

Payment will be in either the form of a County issued check or authorized County credit card. If a purchase order is issued, payment shall be made in accordance to terms noted on purchase order after the occurrence of; a) receipt by County of supplier’s invoice, where invoice date cannot precede shipment date, for payment (which must reference the Purchase Order Number); and b) completion and delivery of all work to be performed and goods to be delivered.
The following infomation is requested for the expediting payments.
Please enter the remittance address below if difference from above.
Address1
Address2
City
State
Zip
First Name
Contact Name
Last Name
Email Address
Contact Email
Phone Number
Contact Phone Number
Fax Number
Contact Fax Number
Payment Terms:*
Continue |Go Back

Section 4

Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S resident alien).
Signature:*
Electronic Signature: By typing your name here your are acknowledging that all of the above statements are true. Signing this document also affirms that the forms are true and correct and that your company has received and accepts the terms of doing business with the County of Lancaster as stated within this website.
Are you requesting an open IFB or RFP?
After submitting the vendor registration form please follow the link below to the Public Purchase website to retrieve a copy of the bid. You will also need to register with Public Purchase. http://www.publicpurchase.com/
Quick link to Public Purchase.
Public Purchase

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
Submit | Go Back

Search Forms:

Vendor Registration Form

Steps

Section 1

Section 2

Section 3

Section 4

Contact Us

Helpful Links

Site Links