WV-1
REV. 06/16/14
STATE OF WEST VIRGINIA - PURCHASING DIVISION
VENDOR REGISTRATION AND DISCLOSURE STATEMENT
AND SMALL, WOMEN-, AND MINORITY-OWNED BUSINESS
CERTIFICATION APPLICATION
Before a vendor is eligible to ll goods and/or rvices to the State of West Virginia, the West Virginia Code§5A-3-12 requires all vendors to have on file with the West Virginia Purchasing Division a completed Vendor Registration and Disclosure Statement. All vendors wishing to participate in the competitive bid process and receive purcha orders from the State of West Virginia exceeding $1,0
00 are required to complete the Vendor Registration and Disclosure Statement (WV-1 form) and pay a $125.00 annual fee. Payment of the annual fee includes email notifications on bid opportunities bad on the commodities and rvices lected upon registering in the Vendor Self-Service (VSS) portal v. Plea complete this form in its ENTIRETY and return it with a check or money order made payable to the STATE OF WEST VIRGINIA in the amount of $125.00. Incomplete forms will not be procesd and will be returned to the vendor. Plea nd completed form and payment to:
Purchasing Division - Vendor Registration
2019 Washington Street East
Charleston, WV 25305-0130
Whenever a change occurs in the information submitted, such change shall be reported immediately in the same manner as required in the original disclosure statement (West Virginia Code §5A-3-12). Vendors doing business with the State of West Virginia are expected to abide by the Vendor Code of Conduct available online at
www.state.wv.us/admin/purcha/vrc/vendorconduct.pdf.
Privacy Notice: The Purchasing Division is required to collect certain information as stated in West Virginia Code §5A-3-12, other applicable ctions of the West Virginia Code, the Vendor Registration and Disclosure Statement forms, and other documents to facilitate the state bidding and contract administration process. This information is stored in a cure environment, but unless specifically protected under state law, any information provided may be inspected by or disclod to the public.
Vendors are also required to be licend and in good standing in accordance with any and all state and local laws and requirements by any state or local agency of West Virginia, including, but not limited to, the West Virginia Secretary of State’s Office, the West Virginia Tax Department, West Virginia Insurance Commission, or other state agencies or political subdivisions. Failure to do so may result in delay of or disqualification from a contract award pursuant to West Virginia Code of State Rules §148-1-6.1.7. If you have any questions concerning this Vendor Registration and Disclosure Statement, plea contact the Purchasing Division at (304) 558-2311.
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION
To Be Completed by the Vendor and Returned to the Purchasing Division
1.Legal Name of Company/Individual
DBA, if any
Bidding Address
City, State, Zip
Principle Contact Person E-mail
Telephone Number Fax Number
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION
To Be Completed by the Vendor and Returned to the Purchasing Division
2.Vendor Classified As:
Individual Government
Sole Proprietor Medical Corporation
Partnership Attorney Corporation
Corporation Non-Profit Organization
Board Member Payroll
Trust Employee
Estate
白菊花3.Taxpayer Identification Number (TIN): If you have an Identification Number, enter it below. All partnerships, corporations, or companies with employees must have an EIN.
海尔公司简介EIN
If you do not have a EIN, plea enter Social Security Number (SSN), Individual Taxpayer Identification Number (ITIN) or Adoptive Identification Number (ATIN) and check the correct below.
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4.(A)Small, Women-Owned, Minority-Owned Business
West Virginia Code§5A-3-59 establishes a procurement certification program in West Virginia for sm红肠怎么吃
all, women-, and minority-owned business. Requirements related to the certification program are provided in the West Virginia Code of State Rules§148-2-1 et q. Note that this certification provides nonresident vendors preference that is equivalent to competing resident (West Virginia) vendors that have applied for resident vendor preference, in accordance with West Virginia Code §5A-3-37. This certification may assist resident small, women-, and minority-owned business when soliciting business in other states.
Certification of Status (Check all tho which apply)
Minority-owned Business [1] means a business concern that is at least fifty-one percent owned by one or more minority individuals or in the ca of a corporation, partnership, or limited liability company or other entity, at least fifty-one percent of the equity ownership interest in the corporation, partnership, or limited liability
company or other entity is owned by one or more minority individuals and both the management and daily
business operations are controlled by one or more minority individuals.
• A “minority individual” means an individual who is a citizen of the United States or a noncitizen who is in full compliance with United States immigration law and who satisfies one or more of the following definitions:
o African American means a person having origins in any of the original peoples of Africa and who is regarded as such by the community of which this person claims to be a part.
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION
To Be Completed by the Vendor and Returned to the Purchasing Division
o Asian American means a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands, including, but not limited to, Japan,
猴子摘桃China, Vietnam, Samoa, Laos, Cambodia, Taiwan, Northern Mariana, the Philippines, a U.S. territory
of the Pacific, India, Pakistan, Bangladesh, or Sri Lanka and who is regarded as such by the
善良的妻子2community of which this person claims to be a part.
o Hispanic American means a person having origins in any of the Spanish-speaking peoples of Mexico, South or Central America, or the Caribbean Islands or other Spanish or Portugue cultures and who
is regarded as such by the community of which this person claims to be a part.
o Native American means a person having origins in any of the original peoples of North America and who is regarded as such by the community of which this person claims to be a part or who is
recognized by a tribal organization.
Small Business [2] means a business, independently owned or operated by one or more persons who are
citizens of the United States or noncitizens who are in full compliance with United States immigration law,
which, together with affiliates, has two hundred fifty or fewer employees, or average annual gross receipts of $10 million or less averaged over the previous three years.
Women-owned Business [3] means a business concern that is at least fifty-one percent owned by one or more women who are citizens of the United States or noncitizens who are in full compliance with United States
immigration law, or in the ca of a corporation, partnership or limited liability company or other entity, at least fifty-one percent of the equity ownership interest is owned by one or more women who are citizens of the
United States or noncitizens who are in full compliance with United States immigration law, and both the
management and daily business operations are controlled by one or more women who are citizens of the United States or noncitizens who are in full compliance with United States immigration law.
(B)Other Federal Designations
Additionally, by providing the following information, I reprent that this enterpri is a small business as defined by the Code of Federal Regulations, Title 13, Part 121, as appended - which co
ntains detailed industry definitions and related procedures - and/or the characteristics of the enterpri's control, operation and/or ownership are accurately reflected in the information provided. Check all that apply.
Disabled Small Business Ownership [4]
Veteran Small Business Ownership [5]
5. Are you registering as a new vendor with the Purchasing Division? No Yes信用卡还款
6. Are you updating the information previously submitted? No Yes
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PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION
To Be Completed by the Vendor and Returned to the Purchasing Division
7. Are you completing this form to register a branch/division/subsidiary? No Yes
8. Is the Legal Company’s address the same for ordering and payment? No Yes
If the ordering or payment address are different for the Parent Company or the branches, divisions or subsidiaries, plea enter this information below:
Ordering Payment
Address:
City, State, Zip:
Ordering Payment
Address:
City, State, Zip:
9. Commodity Codes: You may register for commodity codes for the products and rvices that you offer, which will provide you with bid opportunity alerts and notifications should you become a paid registered vendor. To perform this function, visit the Vendor Self-Service (VSS) Portal at wvOASIS.g
ov.
10. List the name, title, city and state of residence for all owners/officers. If the vendor is an individual, list his or her name and city and state of residence, and, if he or she has associates or partners sharing in his or her business, list their names and city and state of residence. If the vendor is a firm, list the name and city and state of residence of each member, partner or associate of the firm. If the vendor is a corporation created under the laws of this state or authorized to do business in this state, list the names and city and state of residence of the president, vice president, cretary, treasurer and general manager, if any, of the corporation; and the names and city and state of residence of each stockholder of the corporation owning or holding at least ten percent of the capital stock thereof. Attach an additional sheet if space is needed.
Name Position City and State of Residence
If the vendor has only one owner/officer, list the name, position, and city and state of residence above and plea initial here:
VENDOR REGISTRATION AND DISCLOSURE STATEMENT AND SMALL, WOMEN-, AND MINORITY-OWNED BUSINESS CERTIFICATION APPLICATION
魅力PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION
To Be Completed by the Vendor and Returned to the Purchasing Division
11. List the name and telephone number of one or more banking institutions to rve as reference for the vendor.
12. What is the latest Dun & Bradstreet number and rating on the vendor?
13. Is the vendor acting as an agent for some other individual, firm or corporation? If yes, attach statement of the
principal authorizing such reprentation.
No
Yes
By signing below and submitting this form, the vendor certifies and acknowledges that: 1) it has obtained all licens, certifications, and authorizations necessary to lawfully conduct business in the state of West Virginia; and 2) that the asrtions made by completing this form and delivering it to the Purchasing Division are accurate and true in accordance with the applicable law and rules. As authorized agent of the vendor named herein, I do solemnly swear that the above information is true and complete, in accordance with West Virginia Code§5A-3-12(e).
In the event that the vendor is applying for certification as a small, women-, or minority-owned business, the vendor’s signature below further certifies that: 1) the state in which the vendor has its headquarters or principal place of business does not deny a like certification to a West Virginia bad small, women-owned, or minority-owned business; 2) the state in which the vendor has its headquarters or principal place of business does not provide a preference to small, women-owned, or minority-owned firms that is unavailable to West Virginia bad business; and, 3) that it has read and understands this form, along with the law and rules governing certification as a small, women-owned, or minority-owned business.
Authorized Agent of Vendor (Print Name) Authorized Agent (Signature)
Title
Date
PURCHASING DIVISION
USE ONLY
Vendor ID:
Check No. :
Memo No. :
Date:
Entered by:
