Vendor Profile Form
New Vendor Qualifications for Material and/or Service Acquisitions
The undersigned Vendor certifies that the information herein is true, complete, and accurate.
Vendor Legal Na
me: __________________________________________________________________
D/B/A: _______________________________ Federal Tax ID/TIN: __
If a SS#, please mail the form to us.
__________________________
Business Address: ____________________________________________________________________
Phone: _______________________________ Fax: _________________________________________
Email
(Provide email address that will be authorized to receive Purchase Orders): ____________________________
Point of Contact: _____________________________________________________________________
A/R or Accounting Contact: _____________________________________________________________
Remit to address
(if different from above): ____________________________________________________
In the space provided below, please describe the product, service, or specialty that your company offers.
____________________________________________________________________________________
____________________________________________________________________________________
Please include the first 4 digits of the UNSPSC code: ____
(Use this website to search for your code http://www.unspsc.org/search-code)
_____________________________________
___________________________________
Dun and Bradstreet Number (if any): _____________________________________________________
Years in business under present name: ___________________________________________________
Bank References: _____________________________________________________________________
Address: ____________________________________________________________________________
Contact Name: _______________________________________________________________________
Contact Phone: ______________________________________________________________________
Has your firm had any judgments, claims, arbitration proceedings, or suits pending or outstanding over
the last five (5) years? If yes, explain with amount of claim and brief description.
List any/all information regarding lapse, revocation, denial, debarment or other negative action in
connection with any required certification which has occurred over the last five (5) years.
Colgate University may, upon request, require a copy of vendor’s financial statement (assets/liabilities) preferably audited.
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Please indicate your organization’s type or status below (check all that apply):
Corporation
Small Business
Large, Minority (LM)
Small, Minority (SM)
Historically Black Colleges/University (HBCU)
Small Disadvantaged Native American (SDNA)
Large, Minority, Woman-Owned (LMW)
Large, Non-Minority, Woman-Owned (LNW)
Small, Non-Minority (SN)
Disabled Owned Business
Small, Disadvantaged (SDV)
HUB Zone
Americans with Disabilities Act (ADA)
Independent Contractor
Minority Business (MBE)
Disadvantaged Business Enterprise (DBE)
Small Disadvantaged (SDBA)
Small Disadvantaged, Hispanic American (SDHA)
Small, Disadvantaged, Subcontinent-A
sian American
Fe
male Business Enterprise (FBE)
Small, Minority, Women (SMW)
Small, Non-M
inority,
Women (SNW)
Large, Non-Minority
(LN)
Veteran Owned Business
Veteran-Owned Small Business Concern (VOB)
Woman O
wned Business Enterprise (WBE)
Limited Liability Partnership Joint
Other (Please explain below)
_______
___________________
__________________________________________________________
Does
Vendor’s business currently have a Vendor Diversity Program in place?
Yes No
If Ve
ndor answered “yes”, please provide the name and telephone number of Vendor’s Program
Coordinator: _________________________________________________________________________
W-9: Please attach your W-9 with this qualification form. If the Tax ID contains a SS#, please mail the
form to the Colgate Purchasing office address listed below.
Cert
ification
I certify that:
1. The number shown on this form is mu correct taxpayer identification number.
2. I have read, reviewed, and accept the Colgate University Purchasing Terms and Conditions:
http://www.colgate.edu/offices-and-services/purchasing
Signa
ture: ___________________________________________________________
Name (Print): ___________________________________________________________
Title: ____________________________________________________________
Date: ____________________________________________________________
Colgate University
Purchasing Department
13 Oak Drive
Hamilton, New York 13346
Telephone: 312-228-7838, Fax: 315-228-7828
Email: purchasing@colgate.edu
Visit our website at http://www.colgate.edu/offices-and-services/purchasing
