SOLICITATION ADDRESS (where purchase orders and solicitations for bids/proposals will be mailed)

 COMPANY NAME:

 DOING BUSINESS AS:

 STREET:

 CITY, COUNTY, STATE, ZIP:

 CONTACT:

 TELEPHONE & FAX:

 E-MAIL:

 REMITTANCE ADDRESS (where payment will be mailed if different from above address)

 COMPANY NAME:

 STREET:

 CITY, STATE, ZIP:

 CONTACT:

 TELEPHONE & FAX:

 E-MAIL:

COMPANY INFORMATION:

How Long in Present Business:

Does your company have a local office or representative in El Paso County:

 YES

 FEDERAL ID #         or

 SOCIAL SECURITY #

 AUTHORIZED REPRESENTATIVE(S)   (Please Type or Print)

 NAME

 TITLE

DOES ANY EMPLOYEE OF EL PASO COUNTY HAVE A FINANCIAL INTEREST IN YOUR COMPANY?  

 YES

IF YES, NAME OF EMPLOYEE

& RELATIONSHIP:

MINORITY BUSINESS ENTERPRISE:  A minority business enterprise means a small business entity, as defined by Section 3 or

Section 8(a) of the Small Business Act, in which 51% or more if the voting shares and interest in the enterprise is owned by minority individuals and that the minority ownership of the enterprise controls the management, investment and daily business operations of the company.

WOMAN BUSINESS ENTERPRISE:   A woman business enterprise means a small business entity, as defined by Section 3

of the Small Business Act, in which 51% or more of the voting shares and interest in the enterprise is owned by female individuals and that the female ownership of the enterprise controls the management, investment, and daily business operations of the company.

SOCIALLY AND ECONOMICALLY DISADVANTAGED INDIVIDUALS:  Those individuals who are citizens of the United States and

who are African Americans, Hispanic Americans, Native Americans, or Asian Pacific Americans and any other minorities or individuals found to be disadvantaged by the Small Business Administration pursuant to Section 8(a) of the Small Business Act.

PLEASE LIST A MAXIMUM OF (10) COMMODITY CODES (from attached list)

CODE

DESCRIPTION

CODE

DESCRIPTION

FOR ASSISTANCE OR ADDITIONAL COMMODITY CODES, CONTACT THE PROCUREMENT & CONTRACTS DEPARTMENT (719)-520-6402

Submit this form and mail IRS Form W-9 to:

EL PASO COUNTY FINANCIAL SERVICES DEPARTMENT ATTN:  Nora Todd

27 E. VERMIJO AVE., 5^th FLOOR, COLORADO SPRINGS, CO 80903

PHONE :719-520-6429          FAX: 719-520-6428

    (P&C 1/02)