City of Des…

                                                       City of Des Moines
                                           Department of Finance ­ Purchasing Division
                                                 City Hall, 400 Robert D. Ray Drive
                                                    Des Moines, Iowa 50309

                                                 Vendor Application Form


1.     Business name:                                                                                        Years in Business:
2.     Business address:
                                           (Street)                          (City)                      (State)            (Zip Code)
3.     Remittance Address:
       Federal Identification                                                          Social Security
       Number (FEIN):                                                                  Number (if applicable):

4.     Type of organization:    Corporation           Partnership      Individual           Other (Define)
5.     If corporation indicate in which state:                                      When:
       (Attach additional corporation and/or company data)
6.     Does any City of Des Moines employee hold an office as principal, director, partner, or hold any remunerative position in this
       company?
               Yes       (Attach list of names, positions, and departments)                   No
7.     Indicate classes of equipment, supplies, material, and/or services on which you desire to bid/sell:
                                                                                                              (Please attach separate list)
                                                                                                              (Please attach separate list)
8.     Specific brand names of items handled:
                                                                                                             (Please attach separate list)
9.     Type of business (Check more than one if applicable):
       A.   Manufacturer or producer                      D. Construction concern                  G. Professionally licensed
       B.   Dealer with inventory stock                   E. Distributor                           H. Other (define)
       C.   Dealer without inventory stock                F. Service establishment
10.    Type of operation:
       A.   Is your firm located within the corporate limits of the City of Des Moines?                            How long?
       B.   Does your firm pay property taxes on a plant or office to the City of Des Moines?
       C.   Does your firm pay rent to a landlord who pays property taxes on a plant or office to the City of Des
            Moines?
       D.   Gross receipts/sales last year:      $
       E.   Number of Employees:          Company-wide                                 In Des Moines
       F.   Are you a minority or disadvantaged owned concern (at lest 51 percent owned, controlled, and
            actively managed by one or more minorities, or if a publicly-owned concern, at least 51 percent of
            the stock owned by one or more minorities)?
       G.   Are you a woman owned concern (at least 51 percent owned, controlled, and actively managed by
            one or more women, or if a publicly-owned concern, at least 51 percent of the stock owned by one or
            more women)?
11,    Vendor contact person(s):




12.    Bank reference:                                                      Address:
13     The undersigned certifies that the information contained herein is correct. I understand that misrepresentation may be cause
       for removal from the qualified vendor list and any other penalties allowed by law. Further, I affirm that the undersigned
       company's employment practices do not discriminate because of age, race, creed, color, sex, national origin, religion, or
       disability.
Firm                                                                         Signed
E-mail address                                                                                 (Name and title of person signing)
Fax number
Toll free number:                                                              Date
                          Instruction for Vendor Application Form
                                          (Type or print in ink)


1. Enter company name and number of years in business.

2. Enter address to which bids and purchase orders are to be mailed.

3. Enter address to which remittances are to be mailed. Enter Federal Employer identification
   number. If an individual, enter social security number.

4. Check appropriate box.
5. Indicate state in which incorporated and when.

6. Indicate if any City of Des Moines employees hold a remunerative position in your company.

7   Enter commodities and/or services you wish to bid. Enter standard industrial classification (SIC
    code) if known.

8. Enter brand names of commodities handled.

9. Check appropriate line.
10. Answer all questions, A through G.

11. Indicate principal officer of the company.

12. Indicate principal bank reference.

13. To be signed by an officer of the company.
14. Please mail this completed form to:

                Department of Finance
                Division of Purchasing
                City Hall, 400 Robert D. Ray Dr.
                Des Moines, Iowa 50309

15. Acceptance of this application by the City does not guarantee the automatic mailing of all
    Invitations to Bid for equipment or supplies the Vendor has listed in item 7. The Purchasing
    Division will select a sufficient number of vendors from the Approved Vendors List to receive
    copies of solicitations in order to insure adequate competition. However, any interested vendor
    may request a copy of any bid solicitation by contacting the Purchasing Division.




CDM-PA-1-2001