Fillable Printable Dekalb County Supplier Registration Package - Georgia
Fillable Printable Dekalb County Supplier Registration Package - Georgia
Dekalb County Supplier Registration Package - Georgia
DeKalb County Supplier Registration Package (Department of Purchasing and Contracting Form # 16)
Page 1 of 7
DEPARTMENT
OF
PURCHASING and CONTRACTING
DEKALB COUNTY SUPPLIER REGISTRATION PACKAGE
Date Application Submitted: ______________
Please return this registration package by fax, e-mail or postal mail to:
DeKalb County Department of Purchasing and Contracting
1300 Commerce Drive
Decatur, Georgia 30030
For information, telephone: 404-371-7051
Fax: 404-371-7006
E-mail: pcadmin-ops@co.dekalb.ga.us
Initial Application: ______ Revision: ______
Enter Full Legal Name of Firm
Enter Parent Firm’s Name, if applicable
Enter Your DBA name, if applicable
Enter Federal Tax ID Number (EIN): __________________________________________________
OR
Enter Social Security Number if applicable: _____________________________________________
Required by the Internal Revenue Service for reporting purposes. Your firm cannot be added to our Supplier Master File without either
a Federal Tax ID Number or Social Security Number.
Primary Business Classification (check only ONE)
1. Distributor ____ 5. Court Supplier (Recorder, Judge, Attorney, interpreter, expert witness)
____
2. Service Provider ____ 6. Manufacturer
____
3. Freight Carrier ____ 7. Non-Profit
____
4. Government Agency ____ 8. Professional Association
____
Is your Organization 1099 reportable? Yes ______ No ______
If you checked “Yes” above, please circle ONE appropriate category:
Please check ONE
Your organization type is:
1. Attorney
____
1. Individual ____
2. Medical Facility or Physician
____
2. Proprietorship P _ _ _ _
3. Partnership
____
3. Other Non-employee Compensation
____
4. Corporation (LLC/LLP/INC) ____
If incorporated, which state? _________ Date Business Started
__________________________
DeKalb County Supplier Registration Package (Department of Purchasing and Contracting Form # 16)
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Business or Professional License
If a business of Professional License is required in your jurisdiction or profession a copy of that license should be on file with DeKalb County
Business License Number
Issuing City, County or State
Professional License Number
Issuing City, County or State
Check here if a Business License IS NOT required for this type of firm in this City County, or State. ____
City, County, or State ___________________________________________
Check here if a Professional License IS NOT required for this type of firm in this City County, or State. ____
City, County, or State ___________________________________________
NOTE: Please attach listing of any additional addresses not included below
:
Corporate Address (Purchasing Site) where Purchase Orders are sent)
Street Address: _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
County _______________________________________________________________________________
City
___________________________________
State/Province
Postal Code
Email Address
______________________________________________
RFQ/Bid Address (RFQ Only Site) where sealed bids are to be sent
Street Address: __________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
County ________________________________________________________________________________
City
_________________________________
State/Province
________________
Postal Code
______________________
Email Address
Required Field to Receive RFP and ITB notices
automatically
__________________________________________
DeKalb County Supplier Registration Package (Department of Purchasing and Contracting Form # 16)
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Billing or Remit to Address (Pay Site)
Street Address: ________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
County ________________________________________________________________________________
City
_______________________________
State/Province
________________
Postal Code
________________________
Email Address
__________________________________________
*DeKalb County will send Solicitation Notices via email. If you wish to receive Notices at a different email
address rather than the one provided, please enter that email address below.
Email: _____________________________________________________________________________
CONTACTS:
First Contact Person Second Contact Person
1
st
Contact Person’s Name
_________________________________
2
nd
Contact Person’s Name
_______________________________________
1
st
Contact Person’s Title
__________________________________
2
nd
Contact Person’s Title
_______________________________________
1
st
Contact Person’s Voice Line
________________________________
2
nd
Contact Person’s Voice Line
______________________________________
1
sr
Contact Person’s E-Mail
________________________________
Required Field
2
nd
Contact Person’s E-Mail
_____________________________________
Required Field
(NOTE: Please attach any additional contact information)
DeKalb County Supplier Registration Package (Department of Purchasing and Contracting Form # 16)
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COMMODITIES/SERVICES PROVIDED:
In order to properly place Suppliers on the appropriate Supplier Lists for sourcing goods and services,
Suppliers must identify what products and service classifications they offer by selecting the appropriate 5 –
Digit National Institute of Governmental Purchasing (NIGP) Commodity and Service Codes. If you do not
know your NIGP codes, please look them up at:
E-COMMERCE
We have the capability to conduct computer-to-computer transactions and place orders directly into some
supplier’s order entry system.
Are you interested in pursuing B2B (E-Commerce) opportunities with DeKalb County?
Yes ______ No ______
Note on E-Commerce, Email, NIGP Codes, Punchout, and automatic solicitation notifications:
DeKalb County has the ability to automatically notify our registered suppliers when we have advertised formal Invitation to Bid (ITB)
and Request for Proposal (RFP). If you would like to receive these notifications we must have an email address and the 5-digit NIGP
Code for the Goods and Services you would like to sell the County.
The National Institute of Governmental Purchasing has created a list of commodity Codes called NIGP codes. NIGP Codes help identify
goods and services commonly purchased by governmental entities.
Punchout is an E-Commerce Solution provided by our automated purchasing system allowing our P.O. system to communicate directly
with a supplier’s order entry system.
http://www.co.dekalb.ga.us/purchasing/pdf/NIGPcodeLookup.pdf
DeKalb County Supplier Registration Package (Department of Purchasing and Contracting Form # 16)
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LOCAL SMALL BUSINESS ENTERPRISE ORDINANCE
The DeKalb County Government has a Local Small Business Enterprise Ordinance. The Ordinance requires
prime contractors to make a good faith effort to use LSBEs for twenty percent (20%) of the total contract award on
all qualified sealed solicitations.
To qualify for certification with DeKalb County Government as a LSBE, your business must operate and be located
in the ten (10) county Atlanta Metropolitan Statistical Area (MSA) for at least one year prior to the submission of
your application for certification. The MSA includes the following Georgia Counties: Cherokee, Clayton, Cobb,
DeKalb, Douglas, Fayette, Fulton, Henry, Gwinnett, and Rockdale.
There are two (2) types of LSBE certifications: (1) LSBE-DeKalb and (2) LSBE-MSA.
Certified LSBEs located within DeKalb County (LSBE-DeKalb) and prime contractors utilizing them shall receive
ten (10) percentage points in the initial evaluation of their response to any Request for Proposal and a ten (10)
percent preference on all responses to any Invitation to Bid.
Certified LSBEs located outside of DeKalb County but within the MSA (LSBE-MSA) and prime contractors
utilizing them shall receive five (5) percentage points in the initial evaluation of their response to any Request for
Proposal and a five (5) percent preference on all responses to any Invitation to Bid.
Applications for certification as a Local Small Business Enterprise (LSBE) are available online. Please feel free to
contact the Contract Compliance Division by email at compliance@dekalbcountyga.gov or by telephone at (404)
371-7051 with any questions pertaining to the LSBE Ordinance or certification.
I am interested in being certified as a: (please check all that apply)
_______ (LSBE) See above.
_______ (WBE) A business that is at least 51% owned and controlled by one or more women.
_______ (MBE) A business that is at least 51% owned and controlled by one or more minoritie s.
Note: No Benchmark Required and No Preference Granted For MBEs or WBEs.
Contact Person: ___________________________________
Contact me by email: _______________________________
Telephone: ______________________________________
Has your firm been certified as an MBE in another jurisdiction? ______ (Yes / No)
If yes, what jurisdiction? ___________________________________________________________________
Has your firm been certified as an WBE in another jurisdiction? ______ (Yes / No)
If yes, what jurisdiction? ___________________________________________________________________
DeKalb County Supplier Registration Package (Department of Purchasing and Contracting Form # 16)
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Potential Conflict Disclosure
Does any current or former DeKalb County Board of Commissioners, CEO, Officer, or Employee hold an
interest of 5% or more, or any other interest, in the business or in any of the business subcontractors?
(“Interest” as used herein also includes membership on the board of directors of “for-profit” corporations.)
Yes ______ No ______ Unsure ______
If Yes or Unsure, please provide the following information:
Name: ______________________________________________________________________________________
Position: _____________________________________________________________________________________
Organization: ________________________________________________________________________________
Business/Subcontractor: _______________________________________________________________________
Interest Owned: ______________________________________________________________________________
D o e s a n y m e m b e r o f t h e i m m e d i a t e f a m i l y o f a n y c u r r e n t o r f o r m e r D e K a l b C o u n t y B o a r d o f
Commissioners, CEO, Officer, or Employee hold an interest of 5% or more, or any other interest, in the
business or in any of the business subcontractors? (“Interest” as used herein also includes membership on the
board of directors of “for-profit” corporations.)
Yes ______ No ______ Unsure ______
If Yes or Unsure, please provide the following information:
Name of Relative: _____________________________________________________________________________
Relationship: _________________________________________________________________________________
Name of DeKalb County Personnel or Employee: __________________________________________________
Comments: __________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
DeKalb County also reserves the right not to do business with anyone related by blood or marriage to anyone
in the categories of persons listed above when the relationship has the appearance of a “conflict-of-interest”.
Is the business aware of any relationships, not identified above, that may create the appearance of a “conflict-
of-interest”?
Yes ______ No ______ Unsure _______
If Yes or Unsure, please describe (use a separate sheet if necessary):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
DeKalb County Supplier Registration Package (Department of Purchasing and Contracting Form # 16)
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_____________________________________________________________________________________________
YOU MUST COMPLETE
the Federal Form W-9 from the link below
or
WE CANNOT
add your firm to our Supplier Master file. The Internal
Revenue Service requires us to maintain this information.
THE W-9 CANNOT BE SUBMITED ELECTRONICALLY. THE IRS
REQUIRES A PHYSICAL SIGNATURE. THE W-9 MUST BE COMPLETED,
PRINTED, SIGNED AND EITHER MAILED OR FAXED TO COMPLETE
THE SUPPLIER REGISTRATION PROCESS!
Authorized Signature
I hereby swear or affirm that the information given on this Supplier Information Questionnaire is true and
correct to the best of my knowledge and belief, and I understand that this information will be considered
material in the evaluation of quotations, bids, and proposals to perform work for DeKalb County.
If there is a change in status that affects the information provided in this Questionnaire, the undersigned
agrees to provide notice of change to DeKalb County Department of Purchasing and Contracting within ten
(10) days after said change.
FIRM: ______________________________________________________________________________________
BY: ____________________________________________
( S i g n a t u r e )
NAME: ____________________________________________________________________________________
TITLE: ____________________________________________________________________________________
FOR USE BY THE Dekalb County DEPARTMENT OF PURCHASING AND CONTRACTING ONLY
First Follow-up Date: _____________________ Final Follow-up Date: _________________________
http://www.irs.gov/pub/irs-pdf/fw9.pdf
