CPS - Bidder's Application

	Chesapeake Public Schools Bidder's Application Form	Purchasing Department School Administration Building 312 Cedar Road Chesapeake, VA 23322 (757) 547-0265 Fax- (757) 547-0279
	Individuals or companies interested in being added to the Chesapeake Public Schools bidders' list must file this application with the Purchasing Department. Please notify Chesapeake Public Schools of all changes in your name, company name, address, telephone number, fax number, etc., and any deletions or additions you are interested in providing. IT IS IMPERATIVE THAT THE APPLICANT COMPLETE ITEM #13 (Please read carefully) Printable Application

Check one
This is my first application
This is a revised or re-application

1. Full Name of Firm:

Address

Street
City	State Zip

Email Address
Company Website

Toll Free Phone	() - -
Business Phone	() - -
Fax Number	() - -

2. Type of Organization
Proprietorship	Partnership	Corporation	LLC

3. Applicant is a (check all that apply)
Manufacturer	Supplier	Authorized Distributor	Internet Sales Company
Retailer	Wholesaler	Factory Representative or Agent

4. Principals- complete all of the following:
Owner/President	Phone	() - -
Manager	Phone	() - -
Area Sales Representative	Phone	() - -
Contact Person for Bid/RFPs	Phone	() - -

5. Annual Gross Sales
$250,000 or less	$250,001 - $500,000	$500,001 - $750,000	More than $750,001

6. Number of Years in Business.

7. Do you hold a Virginia State Contractors License?Yes No
(If yes, please provide your Virginia State Registration Number and information concerning your Trade Classification below)

Virginia State Registration Number

8. Choose one if you answered yes to number 7:

Trade Classification
(i.e. plumber, carpenter, mason)

References: 9. School Districts and/or municipal governments in Virginia where you have been a successful bidder (within the past 5 years) including contact person, and number of years as a successful bidder with each reference:
Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

10. Other Business References (within the past 5 years) including contact person and number of years for which your company has provided services:
Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

Name:	Phone: () - -
Address:
Contact:	No. of Years

11. Federal Identification Number (FIN) issued by the Internal Revenue Service:

12. The above named firm hereby certifies that it is classified as follows: CHECK ALL THAT APPLY
Small/Disadvantaged	Handicapped/Disabled
Vietnam Era Veteran	Non-Profit Organization
Women-Owned (non-minority)	Asian Pacific American
African American	Eskimo
Hispanic	Native American
Other(specify)

13. PLEASE LIST BELOW THE NIGP CODES FOR THOSE TYPES OF EQUIPMENT, SUPPLIES, OR SERVICES YOUR
     COMPANY IS CAPABLE OF PROVIDING AND FOR WHICH YOUR COMPANY WISHES TO RECEIVE BIDS/RFPs.
     NIGP CODES ARE AVAILABLE HERE.
You must have Adobe Acrobat Reader to view the NIGP codes. Download Adobe Acrobat Reader here.

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14. Additional comments/information

I hereby certify that the information supplied herein is correct and that neither the applicant nor any person(s) connected with the applicant as a principal or officer, to my knowledge, is now debarred or otherwise declared ineligible by any agency of the Federal, State and/or Local Government from any type of bidding.

Name and title of person authorized to sign:
By placing your initials in the block to the right you agree that this serves as your signature.