Business Name

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Tax Identification Number

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Order Address

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Pay to Address

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Telephone

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Fax

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Email

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website URL

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Contact Person

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Business is a:

Corporation
Proprietorship
Partnership
Other:

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Primary business classification:

check all that apply

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HAS APPLYING FIRM, ITS PARTNERS, DIRECTORS, OFFICERS, DIRECT OR INDIRECT OWNERS OF 10% OR MORE OF ITS COMMON STOCK BEEN CONVICTED OF ANY TYPE OF CRIMINAL OFFENSE WITHIN THE LAST 5 YEARS, OR IS AN INDICTMENT CURRENTLY PENDING? NO YES

(If yes, you may be required to provide detailed explanation at a later time).

No
Yes

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LIST BELOW THE NAMES AND ADDRESSES OF ALL INDIVIDUALS, PARTNERSHIPS, CORPORATIONS OR ANY OTHER ENTITY WITH 10% OR GREATER INTEREST IN THE FIRM NAMED IN ITEM 1A ABOVE. IF ADDITIONAL SPACE IS NECESSARY, LIST ON AN ATTACHED SHEET. IF THERE ARE NO OWNERS WITH 10% OR MORE INTEREST IN YOUR COMPANY, ENTER “NONE” BELOW (N.J.S.A.52:25-24.2)

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The Comprehensive Iran Sanctions, Accountability, and Divestment Act of 2010 (CISADA) prohibits state and local government entities from entering into contracts with companies doing business with Iran was signed into law by Gov. Christie on Tuesday. The new law applies to businesses that trade in the areas of energy, finance or construction with Iran.

I hereby certify that the business submitting a request to be added to the Bidder's List does not fall under the aforementioned list

I hereby certify that the business submitting a request to be added to the Bidder's List does not fall under the aforementioned list
Other:

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CERTIFICATION. I, being duly authorized, certify that the information supplied here (including all attached pages) is correct and that: (Check all appropriate boxes.)

Neither the applicant nor any person (or concern) in connection with the applicant as a principal or officer so far as is known, is now debarred or otherwise declared ineligible by an Agency of Government from bidding for contracts to furnish labor, materials, supplies, and/’or services; The applicant will comply with the New Jersey Conflicts of Interest Law (N.J.S.A. 52:13D-12 et seq.); I hereby certify that the statements in the Bidders Mailing List Application are true. I am aware that if any of this information is willfully false, I am subject to punishment.

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The request of W-9 and NJ business registration are required upon execution of an awarded contract

(No response necessary)

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Bidder's List Form