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HCCS Vendor Application |
| Contact Information |
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Company Name: |
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Owner's Name: |
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Physical Address: |
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City / State / Zip: |
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Remittance Address Same as Physical Address. |
| Remittance
Address: |
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| City / State
/ Zip: |
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Phone Number: |
Ext.
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| Fax Number: |
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E-mail Address: |
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| Company
Website (URL): |
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Company Contact:
(Authorized to sign bids/contracts for company) |
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Contact's Title: |
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Contact's Phone Number: |
Ext.
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| Contact's Fax Number: |
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| Local Company Representative:
(if different from above) |
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| Local Rep's Title: |
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| Local Rep's Phone Number:
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Ext.
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| Local Rep's Fax Number: |
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| Company Data |
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Type of Entity: |
If other:
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Federal Tax ID Number: |
(SSN if Sole Proprietorship) |
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Years in Business: |
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Number of Employees: |
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Are you an employee of HCCS? |
Yes
No
*Reference HCCS’s purchasing policy for Conflict of Interest Statement. |
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List three references (local or otherwise) which have been or are now
your customers: |
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List and describe products and/or services that your business offers: |
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| D-U-N-S: |
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Categories: |
Select
Categories
To remove items from the list above, highlight the category and hit Remove
from List.
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Business Classification: |
A. Minority-Owned Business
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Yes |
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No |
| B. Women-Owned Business
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Yes |
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No |
| C. Small Disadvantaged
Business |
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Yes |
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No |
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D. Small Business |
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Yes |
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No |
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E. Historically Underutilized
Business |
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Yes |
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No |
| HCCS is an equal opportunity / educational
institution, which does not discriminate on the basis of race, religion,
national origin, gender, age or disability. HCCS encourages small and
disadvantaged businesses to seek procurement opportunities. |
A. A minority-owned business, as used in
this form, refers to a business that is at least 51-percent owned by one
or more minorities, and whose management and daily business operations
are controlled by one or more minorities.
B. A women-owned business, as used in this form, refers to a business
that is at least 51-percent owned by one or more women, and whose management
and daily business operations are controlled by one or more minorities.
C. A small disadvantaged business, as used in this document, refers to
a small business 1) that is at least 51-percent owned by one or more individuals
who are both socially and economically disadvantaged, or a publicly-owned
business whose stock is at least 51-percent owned by one or more socially
and economically disadvantaged individuals and 2) whose management and
daily business operations are controlled by one or more such individuals.
Socially disadvantaged individuals include those who have been subjected
to racial or ethnic prejudice or cultural bias in American society due
to their identities as members of particular groups and without regard
to their individual qualities. Social disadvantaged status must stem from
circumstances beyond their control.
D. A small business, as used in this form, refers to a business that is
independently owned and operated, and which is not dominated in its field
of operation. Please review small business criteria at http://www.sba.gov
for further information.
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Is your business certified? |
Yes
No |
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yes, what type of certification(s) does your business have? |
HMBC |
SBA 8(a) |
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City of Houston |
Metro
Other
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WBEA |
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e-Business Readiness |
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| By choosing to submit this
form, you certify that the information you have provided above is true
and accurate. |
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