Vendor Application Form Procurement & Contract Services

PO Box 4638

Clarksville TN 37044

www.apsu.edu/procurement

Fax application to (931) 221-6300 or email to appurchasing@apsu.edu

1. Company Name & Bid Address 2. Address to which payments are to be mailed (if same as #1,

leave blank)

3. Telephone 4. Telephone (toll free)

5. Fax 6. Name & email of Contact Person

7. Email or fax to send purchase orders 8. Company URL

9. Federal Identification Number (FEIN) 10. Social Security Number (if no FEIN)

11. Type of Organization (Check one)

Individual Partnership

Non-Profit Org Corporation

State of Incorporation:

Year of Incorporation:

12. Kind of Ownership (Check all that apply)

Govt. (GO) Minority

Non-Profit (NO) Woman (WO)

Majority (MJ) Small (SM)

Service-Disabled Veteran (DV)

13. Minority Ethnicity code (Check One)

African American (MA)

Native American (MN)

Hispanic American (MH)

Asian American (MS)

Other Minority (MO) Specify: __________________

14. Annual Gross Sales (Check One)

$0—$499,999

$500,000—$749,999

$750,000—$999,999

$1,000,000—$1,999,999

$2,000,000 and over

15. Type of Business (Check One):

Agriculture, Forestry, & Fishing

Architectural/Design/Engineering

Finance, Insurance & Real Estate

Medical/Healthcare

Service Industry

Mining

Construction

Educational

Manufacturing

Marketing/Communications/

Public Relations

Retail Trade

Wholesale Trade

Transportation,

Commerce & Utilities

Information Systems/Technology

16. Number of Employees:

17. Are you excluded or banned from Federal Pro-

curement or Nonprocurement Programs:

Yes No

18. Preference for reporting purposes:

Small Minority Woman-Owned

Service-Disabled Veteran

19. Commodities: Please provide the three-digit (3) NGIP commodity codes for goods and/or services for which your company

would like to be provided bid opportunities.

21. Certification: I hereby certify that I am an authorized representative of the above company and that all the information as

complet-ed above is accurate and true.

__________________________________________________________________________________________________________

Authorized Signature Title Date

Minority/Ethnicity Form

In order to comply with reporting regulations as required by the State of Tennessee and the United States federal

income tax laws, it is necessary that the following information be provided prior to the issuance of any University

contract.

1. Name of Contractor:

__________________________________________

Federal ID/Social Security Number:

__________________________________________

2. Is Contractor a US citizen?

Yes

No

If no, state country of citizenship

_________________________________________

(If not a US Citizen, please include a copy of Visa with this

form)

3. Kind of Ownership (Check all that apply):

Govt. (GO)

Agency of the State of Tennessee (SA)

Non-Profit (NO)

Majority (MJ)

Minority* (see reverse side for definition)

Woman (WO)** (see reverse side for definition)

Small (SM)***(see reverse side for definition)

Disabled (DO)***(see reverse side for definition)

Service-Disabled Veteran***(see reverse side for

definition)

4. Minority/Ethnicity Code (Check one if applicable):

African American (MA)

Native American (MN)

Hispanic American (MH)

Asian American (MS)

Other Minority (MO)

Specify:___________

5. Preference for reporting purposes: (Note: If Contractor qualifies in multiple categories as small, woman-

owned and/or minority, Contractor is to specify in which category he/she is to be considered for reporting

and classification purposes.)

Small Minority Woman-Owned Service-Disabled Disable-Owned

6. Certification: I certify that all the information as completed above is accurate and true.

_________________________________________________________________________________________

Signature Date

Name (Printed): ______________________________________________

Title: _______________________________________________________

*Minority Ownership Clarification:

"Minority owned business" means a business that is a continuing, independent, for profit business which performs a commercially useful function, and is at least fifty-one percent (51%) owned and controlled by one (1) or more minority individuals who are impeded from normal entry into the economic mainstream because of past practices of discrimination based on race or ethnic background.

"Minority" means a person who is a citizen or lawful permanent resident of the United States and who is:

a) African American (a person having origins in any of the black racial groups of Africa);

b) Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race);

c) Asian American (a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands); or

d) Native American (a person having origins in any of the original peoples of North America).

**Woman-Owned Business Clarification:

A "woman-owned business" means a woman owned business that is a continuing, independent, for profit business which performs a commercially useful function, and is at least fifty-one percent (51%) owned and controlled by one or more women; or, in the case of any publicly owned business, at least fifty-one percent (51%) of the stock of which is owned and controlled by one (1) or more women and whose management and daily business operations are under the control of one (1) or more women.

***Businesses owned by persons with Disabilities Clarification:

”Business owned by persons with disabilities" means a business owned by a person with a disability that is a continuing, independent, for-profit business that performs a commercially useful function, and is at least fifty-one percent (51%) owned and controlled by one (1) or more persons with a disability; or, in the case of any publicly-owned business, at least fifty one percent (51%) of the stock of which is owned and controlled by one (1) or more persons with a disability and whose management and daily business operations are under the control of one (1) or more persons with a disability; "Person with a disability" means an individual who meets at least one (1) of the following: (A) Has been diagnosed as having a physical or mental disability resulting in marked and severe functional limitations that is expected to last no less than twelve (12) months; (B) Is eligible to receive social security disability insurance (SSDI); or (C) Is eligible to receive supplemental security income (SSI) and has a disability as defined in subdivision (A).

****Service-Disabled Veteran Business Enterprise (SDVBE) Clarification:

Tennessee Service-Disabled Veteran owned mean any person who served honorably on active duty in the Armed Forces of the United States with at least a twenty percent (20%) disability that is service-connected meaning that such disability was incurred or aggravated in the line of duty in the active military, naval or air service. “Tennessee service disabled veteran owned business” means a service-disabled veteran owned business that is a continuing, independent, for profit business located in the state of Tennessee that performs a commercially useful function.

Tennessee Service-Disabled Veteran owned means a service-disabled owned business that is a continuing, independent, for profit business located in the state of Tennessee that performs a commercially useful function, and

1. is at least fifty-one percent (51%) owned and controlled by one (1) or more service-disabled owned veterans;

2. In the case of a business solely owned by (1) service-disabled veteran and such person’s spouse, is at least fifty percent (50) owned and controlled by the service-disabled veteran; or

3. In the case of any publicly owned business, at least fifty-one percent (51%) of the stock of which is owned and controlled by one (1) or more service-disabled veteran and whose management and daily business operations are under the control of one (1) or more service-disabled veteran.

*****Small Business Ownership Clarification:

A "small business" means a business that is independently owned and operated for profit, is not dominant in its field of operation and is not an affiliate or subsidiary of a business dominant in its field of operation.

The Governor's Office of Diversity Business Enterprise establishes small business guidelines on industry size standards. The criteria guidelines are required to be met in order for a business to be considered small. The annual receipts or number of employees indicates the maximum allowed for a small business concern and its affiliates to be considered small.

TYPE OF BUSINESS ANNUAL GROSS SALES NO. OF EMPLOYEES

Agriculture, Forestry, Fishing $500,000 9

Architectural / Design / Engineering $2,000,000 30

Construction $2,000,000 30

Educational $1,000,000 9

Finance, Insurance & Real Estate $1,000,000 9

Information Systems / Technology $2,000,000 30

Manufacturing $2,000,000 99

Marketing / Communications / Public Relations

$2,000,000 30

Medical / Healthcare $2,000,000 30

Mining $1,000,000 49

Retail Trade $750,000 9

Service Industry $500,000 9

Transportation, Commerce & Utilities $1,000,000 9

Wholesale Trade $1,000,000 19

PeayPayables ACH Payment Enrollment Form

This form is used for Automated Clearing House (ACH) payments to

provide payment related information to your financial institution. It is

your responsibility to check with your financial institution to confirm that

funds have been deposited.

PAYEE / COMPANY INFORMATION

Name:

Current Mailing Address:

Taxpayer EIN # (required):

Social Security Number if Sole Proprietor (required):

Contact Person Name:

Email Address for Remittance:

Work Telephone #:

FINANCIAL INSTITUTION INFORMATION

Name:

Mailing Address:

City, State and Zip Code:

Nine-digit Routing Transit Number:

Account Number:

Type of Account: Checking Savings

Name of Payee or Authorized Official (please print)

Signature of Payee or Authorized Official:

Title of Payee or Authorized Official:

Date:

Your signature on the ACH Vendor Form states the following:

1) I request and authorize Austin Peay State University (APSU) to deposit any reimbursements or otherapproved payments into my account with the financial institution specified.

2) This authorization will remain in full force and effect until APSU discontinues the service, or until Isubmit a written request to terminate the service. If account information or financial institutionchanges, I understand that I must complete and submit a new authorization. I will submit this requestto the Accounts Payable office in a timely manner as to afford APSU and my financial institution areasonable opportunity to act upon my request.

3) Sole notification of my EFT payment will be delivered to the e-mail address indicated above.

TENNESSEE DEPARTMENT OF REVENUE

TENNESSEE SALES AND USE TAX BLANKET CERTIFICATE OF RESALE

TO: Vendor’s Name

Vendor’s Address

RV-F1300701 INTERNET (12-11)

The undersigned hereby certifies that the merchandise purchased on each order placed is purchased for the reason indicated below. The purchaser must notify theseller in writing if the certificate is no longer valid. [See definition of “resale” in Tenn. Code Ann. Section 67-6-102.]

( )

( )

( )

( )

( )

Resale as tangible personal property or resale of a service subject to tax.

A component part of an article to be produced for sale by manufacturing, assembling, processing, or refining.

Rental or leasing of tangible personal property.

Use in accordance with the provisions of Rule 1320-5-1-.68(4). (A copy of the Direct Pay Permit must be given to the vendor.)

Other (indicate reason):

Sales Tax Registration Number

of Purchaser

Name of Business

Name of Authorized Purchaser

Signature of Authorized Purchaser

AddressEffective Date of Registration

NOTICE

This Certificate must be fully completed and signed before it is valid. Certificate remains in effect until revoked in writing by the purchaser. Once a valid certificateis on file, it is not necessary to obtain additional copies for subsequent purchases.

Any merchandise obtained upon this resale certificate is subject to the Sales and Use Tax if it is used or consumed by the purchaser in any manner and must bereported and the tax paid thereon directly to the Tennessee Department of Revenue.

TENN. CODE ANN. SECTION 67-6-607 MAKES IT A MISDEMEANOR TO MISUSE A CERTIFICATE OF REGISTRATION WITHOUT PAYING THESALES AND USE TAXES AND SUBJECTS THE CERTIFICATE TO REVOCATION.

F23 ATTESTATION

TN Higher Education – Standard Document – August 2018 Page 1 of 1

Subject Contract Number:

Legal Entity Name of the Party Participating in a State Contract:

The Party, identified above, does hereby attest, certify, warrant, and assure that the Party shall not knowingly utilize the services of an illegal immigrant in the performance of this Contract and shall not knowingly utilize the services of any subcontractor or consultant who will utilize the services of an illegal immigrant in the performance of this Contract.

SIGNATURE & DATE:

NOTICE: This attestation MUST be signed by an individual empowered to contractually bind the Party. If said individual is not the chief executive or president, this document shall attach evidence showing the individual’s authority to contractually bind the Party.

Type or print Name of Signatory:

Type or print Title of Signatory:

END OF ATTESTATION

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

LOCJECTPRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $DAMAGE TO RENTEDEACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

INSRLTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF(MM/DD/YYYY)

POLICY EXP(MM/DD/YYYY) LIMITS

PERSTATUTE

OTH-ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

$

$

$

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe underDESCRIPTION OF OPERATIONS below

(Mandatory in NH)OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOSNON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

$

$

$

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSDADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)

OTHER:

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

PHONE(A/C, No, Ext):

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

PRODUCER

INSURED

A

X

X

X X

1,000,000

2,000,000

AX

500,000

State surcharge 2

A

X 1,000,000

2,000,000

B

X

100,000

100,000

100,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

<<SBC#, Project Title>>

Austin Peay State UniversityUniversity of Design & Construction255 Marion Street, Suite 10Clarksville, TN 37044