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2. Company Name*
4. Company Street Address*
6. City
7. State
8. Zip Code
10. County
11. Country
13. Email Address*
14. Fax Number
18. Remittance / Billing Address*
20. City
21. State
22. Zip Code
24. County
25. Country
27. Billing Contact
29. Name*
30. Job Title*
31. Phone Number
32. Email*
34. Sales Contact
36. Name*
37. Job Title*
38. Phone Number*
39. Email*
41. Type of Business
    -- Select One --Contact LaborEducation Services (Training)Equipment SalesLegalMedical ServicesRentalRepairs and ServicesSuppliesOther

    As shown on 1099, used for reporting purposes
42. If "Other", please note:
46. Items your firm wishes to quote for bidder list:*
50. Minority Business Certification*

    Minority group members are Black Americans, Hispanic Americans, Asian-Pacific Americans, Native Americans and women. A minority business enterprise is defined as at least 51% of which is owned by a majority group member, or in case of publicly owned businesses, at least 51% of the stock is owned by minority group members. The wife or spouse being a 51% owner in accord with the State of Texas Statutes of Community property is not a factor as the intent is to measure the participation of women as owners of businesses in their own right. The submitter certifies that his/her firm:

    1. Is a minority owned business enterprise
    2. Is not a minority owned business enterprise
52. Please specify minority classification owner as indicated:
56. To receive a copy of your submission, please fill out your email address before submitting:
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field