Preferred Vendor Application

Introduction

Minority Category*

Company Name*

Parent Company

Physical Address

Address Line 1*

Address Line 2

City

State*

Zip Code*

Physical Address is Home Address

Mailing Address is different than Physical Address

Mailing Address

Address Line 1*

Address Line 2

City

State*

Zip Code

Contact Information

Phone*

Fax

Website

Email*

Key Contact’s Name*

Key Contact’s Title

Owners/Stakeholders

Please list each owner, proprietor, partner, officer, member, director and stockholder. The name listed should include Minority Group Members and Non-Minority Group Members.

Name*

Title*

Gender*

Years of Ownership*

Ownership Role*

Ownership Percentage*

Voting Percentage*

Minority Category*

Name*

Title*

Gender*

Years of Ownership*

Ownership Role*

Ownership Percentage*

Voting Percentage*

Minority Category*

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Key Individuals

Identify those individuals (owners, non-owners and key employees) who are responsible for the day-to-day operations and policy decision-making, including those with prime responsibilities for:

Financial Desisions

Name*

Title*

Signatory on Major Documents

Name*

Title*

Accounts Receivable

Name*

Title*

Marketing/Sales

Name*

Title*

Estimating/Bids

Name*

Title*

Supervision of Field Operations

Name*

Title*

Business Details

Type of Legal Business Structure*

Date Business was Established*

Business Classification*

Geographical Market*

The Business Premises are…*

Locations of Additional Facilities

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Number of Full Time Employees*

Number of Part Time Employees*

Number of Minority Employees*

Number of Tlingit/Haida Employees*

Qualifiers

Is the company bonded?*

YesNo

Bonding/Security Company*

Bonding Limit/Projects*

Total Bonding Limit/Projects*

Is the company insured?*

YesNo

Insured Amount*

Insurance Company

Liability Policy #

Workers Comp Policy #

Is the company a participant in the T&H Business Development Program?*

YesNo

Date Started*

If license or permit is required to provide product or service, provide details

Name of License Holder

Type of License/Permit

License #

Name of License Holder

Type of License/Permit

License #

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Business Description

Please give a concise description of the company products, services, or type of construction. If the company offers more than one product or service, list primary products or services first.

Description*

(max 300 characters)

Duns & Bradstreet Number

Would you also like to be included in the T&H Business Directory?*

YesNo

How did you hear about the T&H Preferred Vendor Program?*

Please Specify*

Has the company previously served as a vendor for Tlingit & Haida?

T&H Department or Subsidiary*

YesNo

Contact Name

Does the applicant business have any subsidiaries or affiliates or is it a subsidiary of another concern?*

YesNo

If yes, please provide the name, address, and telephone number of the subsidiary, affiliate, or parent company.*

Also describe the relationship of the applicant company to the subsidiary, affiliate or parent.

Is the applicant business and/or owner concern involved in any present or pending lawsuit?*

YesNo

References

Please provide three current customer references.

Company Name*

Address*

City*

State*

Zip Code*

Phone*

Buyer*

Product/Service*

Dollar Value*

Company Name*

Address*

City*

State*

Zip Code*

Phone*

Buyer*

Product/Service*

Dollar Value*

+ Add more

TO COMPLETE THIS APPLICATION, PLEASE AGREE TO THE FOLLOWING TERMS.

DECLARATION OF CERTIFICATION OF MINORITY STATUS

I (We) have completed and submitted the preferred vendor application for Tlingit & Haida and hereby certify that the information contained herein and all attachments submitted are true and correct and accurate to the best of my (our) knowledge and belief. I (We) understand that this declaration of certification and the criteria set forth have been developed according to the guidelines established by the Tlingit & Haida Preferred Vendor Program. The certification, when granted, will be for a two year period.

Termination of status may be based upon, but not necessarily limited to, any one of the following:

Cessation of business operation by the minority business concern.
Discovery that any false information was knowingly supplied in the completion of this form or as contained in any attachments submitted.
Failure to provide timely notice or withholding of any notice to the Tlingit & Haida Preferred Vendor Program of the transfer or loss of ownership and/or management and control of the business concern by its minority group members.
Failure or refusal to allow the Tlingit & Haida Preferred Vendor Program and/or its representative access to the company’s place of business upon reasonable notice and demand for the purpose of a site visit.
Sale, exchange, or transfer of ownership of the minority business concern, if such transfer results in the loss of control and ownership of the business concern by the minority group members.

I (We) understand and agree that the Tlingit & Haida Preferred Vendor Program reserves the right to request any further and additional information that it may deem necessary to substantiate the information and representations made by the applicant(s) for certification. I (We) declare that the company in whose name this application is being submitted is at least fifty-one percent owned by one or more minority individuals (as defined herein) and such individuals control, operate, and manage the company.

The undersigned hereby agree(s) to hold the Tlingit & Haida Preferred Vendor Program free and harmless from any and all claims, demands, and damages whatsoever arising out of the presentation of this application and agrees to indemnify and hold Tlingit & Haida harmless for any and all liability in connection with the certification of the information contained in this application.

I (We) hereby declares (declare) under penalty of perjury that all statements made in this application and any attachments hereto true and correct.

Clicking the agree button below signifies that the proprietor, partners, and president of the corporation agree to all the terms above.

I agree to these terms.*

Tlingit and Haida Indian Tribes of Alaska’s preferred vendor program strives to increase business opportunities for qualified applicants. Participants must be at least a 51% majority owner in a Tlingit & Haida citizen-owned business and other Alaska Native and/or American Indian-owned businesses.

Complete the form below to be included in our Preferred Vendor Program.
You will be notified when your application is processed.

Introduction

Physical Address

Mailing Address

Contact Information

Owners/Stakeholders

Key Individuals

Business Details

Qualifiers

Business Description

TO COMPLETE THIS APPLICATION, PLEASE AGREE TO THE FOLLOWING TERMS.

Preferred Vendor Application

Tlingit and Haida Indian Tribes of Alaska’s preferred vendor program strives to increase business opportunities for qualified applicants. Participants must be at least a 51% majority owner in a Tlingit & Haida citizen-owned business and other Alaska Native and/or American Indian-owned businesses.

Complete the form below to be included in our Preferred Vendor Program.You will be notified when your application is processed.

Introduction

Physical Address

Mailing Address

Contact Information

Owners/Stakeholders

Key Individuals

Business Details

Qualifiers

Business Description

TO COMPLETE THIS APPLICATION, PLEASE AGREE TO THE FOLLOWING TERMS.

Complete the form below to be included in our Preferred Vendor Program.
You will be notified when your application is processed.