|
NEW
YORK POWER AUTHORITY SUPPLIER DIVERSITY PROGRAM |
VENDOR PROFILE
(en
español) |
1. TYPE OF RESPONSE
____Initial
____Revision |
2. DATE |
NOTE:
Complete all items on this form. Insert N/A in items not applicable. Please include
company literature or brochure with this form. |
3. NAME AND ADDRESS OF
NYPA ENTITY TO WHICH FORM SUBMITTED
New York Power
Authority
123 Main Street
White Plains, NY 10601-3104
Attention: Contract Administration Division, SDP |
4. NAME AND ADDRESS OF APPLICANT
(include country and nine-digit ZIP+4) |
5. TYPE OF ORGANIZATION
(CHECK ONE):
_______ Individual
_______ Partnership
_______ Non-Profit
_______ Corporation (Incorporated under the laws of the State of __________) |
6. ADDRESS TO WHICH SOLICITATIONS ARE
TO BE MAILED (if different than Item 4) |
7. NAMES OF
OFFICERS, OWNERS OR PARTNERS |
A. PRESIDENT
|
B. VICE PRESIDENT
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C. SECRETARY
|
D. TREASURER
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E. OWNERS OR PARTNERS
|
8. AFFILIATES OF APPLICANT
(Names, locations, nature of affiliation, etc.)
|
9. IDENTIFY EQUIPMENT, SUPPLIES,
AND/OR SERVICES ON WHICH YOU DESIRE TO MAKE AN OFFER
(Provide SIC Codes, if available)
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10. SIZE OF BUSINESS
_______ Small Business
_______ Other than Small Business |
11. AVERAGE NUMBER OF EMPLOYEES
(including affiliates) FOR FOUR PRECEDING QUARTERS (Add "/P" if
for Parent Company)
________ AS OF _____/_____/_____
MO/DAY/YR |
12. AVERAGE SALES OR RECEIPTS FOR
PRECEDING THREE FISCAL YEARS (Add "/P" if for Parent Company)
$________________AS OF _____/_____/_____
MO/DAY/YR |
13. TYPE OF OWNERSHIP (See
definitions in NYPA Guide)
________ Minority Business Enterprise
________ Women-Owned Business Enterprise
NYS M/WBE Certification No.
__________________________ |
14. TYPE OF BUSINESS
________ Manufacturer/Producer
________ Manufacturing Representative
________ Service Establishment
________ Consultant (Personal Services)
________ Regular Dealer
________ Surplus Dealer
________ Construction Concern |
15. DUNS NO. (If available)
|
16. YEAR BUSINESS FORMED?
(Add "/P" if year Parent Company formed)
|
17. PAYEE IDENTIFICATION NUMBERS
A. FEDERAL SOCIAL SECURITY ACCOUNT NUMBER: _______________
B. FEDERAL EMPLOYER ID NUMBER: _____________________________ |
18. COLLECTIVE BARGAINING AGREEMENTS
(List of locals and Trades, if any, with contract expiration dates)
|
19. LICENSING AGREEMENTS
(List any licensing agreements required to provide your product/service, exp. Dates, and
whether your business is licensee or licensor)
|
20. BONDING REFERENCE (List
highest bond received, date and bonding reference) |
| CERTIFICATION: I
certify that information supplied herein (including all pages attached) is correct and
that neither the applicant nor any person (or concern) in any connection with the
applicant as a principal or officer, so far as is known, is now debarred or otherwise
declared ineligible by any agency of the State of New York from making offers for
furnishing materials, supplies, or services to the State of New York or any agency
thereof. |
21. Name/Title of Person Authorized to
sign (Type or Print)
|
22. SIGNATURE |
23. DATE |
