THE OCEAN COUNTY UTILITIES AUTHORITY P.O. Box “P” Bayville, New Jersey 08721 Fax: 732-269-8440 l Tel: 732-269-4500 www.ocua.com

VENDOR APPLICATION PLEASE COMPLETE AND FAX TO OCUA VENDOR #_____________________

COMPANY NAME (FORMAL)

COMPANY PRESIDENT / CEO

SALES REPRESENTATIVE

EMAIL ADDRESS - SALES REPRESENTATIVE

MAILING ADDRESS

CITY

STATE

ZIP

REMITTANCE ADDRESS

CITY

STATE

ZIP

PHONE NO. ( )

TOLL FREE NO. ( )

FAX NO. ( )

COMPANY WEB SITE

FEDERAL TAX I.D. NO. (not resale no.)

NOTE: Failure to provide your Federal Tax I.D. number may result in an Internal Revenue Service imposed penalty per Internal Revenue Service Code Section 3406(a)(1).

TYPE OF ORGANIZATION o INDIVIDUAL: ___________________________________ Name of Owner o CORPORATION: ________________________________ State of Corporation o PARTNERSHIP : o General o Limited o NON-PROFIT AGENCY

NOTICE TO ALL VENDORS DO YOU HAVE A “BUSINESS REGISTRATION CERTIFICATE” FROM THE STATE OF NEW JERSEY? o NO o YES If Yes, Please attach a copy to this application ____________________________________________________________________________________________________________________ WILL YOU ACCEPT OUR PURCHASE ORDER o NO o YES MINIMUM ORDER AMOUNT $________________________________

ALL VENDORS MUST COMPLETE THIS SECTION. 1. Have you ever been bonded? o Yes o No If yes, Name of Bonding Company: _________________________________________________ 2. Have you ever had a bond revoked? o Yes o No If yes, state briefly why: ____________________________________________________ 3. Is there any litigation pending against you? o Yes o No If yes, briefly state why: ____________________________________________ (Be prepared to provide this office with your attorney’s name, case number, and the status of the litigation 4. Is your inventory stocked in the State of New Jersey? o Yes o No If no, where is it stocked? _______________________________

The undersigned swears under penalty of perjury that the foregoing statements are true and correct and that they include all material information necessary to identify and explain the operations of this firm as well as the ownership thereof. Any material misrepresentation will be grounds for terminating any purchase orders or contracts which may be awarded and for initiating action under federal or state laws concerning false statements.

Name (Please Print)

Full Title

Signature Date

Please select Commodity Code(s) from the attached OCSD Commodity Code List. Do not select codes for which you currently do not supply goods or services.
If you choose multiple Commodity Codes, you are required to select ONE Primary Code category (i.e. 0400-Chemicals or 2100-Mechanical Equipment).	PRIMARY CODE: _______________ Multiple Commodities o Yes o No

NOTE: Three (3) consecutive no bids to formal bid/RFP requests will result in your company’s removal from our vendor bid list.

	THE OCEAN COUNTY UTILITIES AUTHORITY COMMODITY CODES
0100 AUTO EQUIP, PARTS & ACCESSORIES 0101 o Auto & Truck Body Repair 0102 o Auto & Truck Dealers, Manufacturing 0103 o Auto & Truck Parts, Access., Service 0104 o Automotive Batteries 0105 o Boat Equipment, Repair, Parts 0106 o Boats and Boat Rental 0107 o Construction Equip. Dealers & Mfrs 0108 o Construction Equipment Rental 0109 o Electric Carts 0110 o Miscellaneous Auto 0111 o Service Station Equip, Parts, Repair 0112 o Tires, Tubes & Tire Service 0113 o Vehicle Rental 0114 o Other _________________________ 0200 FACILITY SVCS & REMODELLING MATERIALS / SUPPLIES 0201 o Accoustical Ceiling Tiles 0202 o Cabinetry 0203 o Doors 0204 o Misc. Hardware & Supplies 0205 o Roofing, Siding Materials 0206 o Tile, Installation, Repair 0207 o Tubs, Showers, Sinks, Toilets 0208 o Wall Coverings 0209 o Windows 0210 o Other _________________________ 0300 BUSINESS & PROPERTY SERVICES 0301 o Appraisers & Surveyors 0302 o Background Music 0303 o Collection Agencies 0304 o Easements/Rights-of-way 0305 o Flags, Flagpoles, Access. & Repair 0306 o Insurance, Risk Management 0307 o Mailing Lists and Labels 0308 o Meeting Rooms, Hotels 0309 o Temp Help Agency: Transcribe/Translate 0310 o Temporary Buildings, Sales 0311 o Other _________________________ 0400 CHEMICALS, WATER / WASTEWATER TREATMENT 0401 o Chlorine (Cl2) 0402 o Ferric Chloride (FeCl3) 0403 o Ferrous Chloride (FeCl2) 0404 o Hydrogen Peroxide (H2O2) 0405 o Hydrochloric Acid (HCI) = Muriatic 0406 o Magnesium Hydroxide (Mg(OH)2 ) 0407 o Peracetic Acid (PAA) = (Acetyl Peroxide) 0408 o Polymers 0409 o Sodium Bisulfite (NaHSO3) 0410 o Sodium Hypochlorite (NaOcCl) – Bleach 0411 o Sodium Hydroxide (NaOH) = Caustic 0412 o Natural Gas 0413 o Other _________________________ Note: Lab chemicals & gases are listed under Lab Supplies		0500 CLOTHING & LAUNDRY SERVICES 0501 o Gloves 0502 o Laundry Services 0503 o Other _________________________ 0504 o Repairs, Alterations, & Misc. Services 0505 o Safety Shoes 0506 o Uniform Dealers & Manufacturing 0600 COMPUTER HARDWARE & SOFTWARE 0601 o Communication Devices 0602 o Computer Printer Supplies (ribbons, paper) 0603 o Computer Printers 0604 o Computer Program /Maint. /Enhancements / Upgrades 0605 o Mid-range/Large Computer Peripherals 0606 o Mid-range/Large Computer Repair & Maint. 0607 o Mid-range/Large Computers /Accessories 0608 o Miscellaneous Computer Items 0609 o PC Hardware Components 0610 o PC Maintenance/Repair Service 0611 o PC Peripherals 0612 o PC Software 0613 o Personal Computers 0614 o Programming: SAP 0615 o Programming: ORACLE 0616 o Programming: Other __________________ 0617 o Programming: Systems 0618 o Other _________________________ 0700 CONCRETE & GLASS PRODUCTS 0701 o Asphalt & Related Products 0702 o Bagged Cement 0703 o Concrete Accessories & Tools 0704 o Concrete Forms 0705 o Concrete Pumper Rental 0706 o Glass Containers 0707 o Glass Dealers & Installation 0708 o Meter Boxes 0709 o Wet Cement 0710 o Other _________________________ 0800 CONSTRUCTION 0801 o Carpentry 0802 o Construction Management 0803 o Contractor, Acoustical 0804 o Contractor, Cement 0805 o Contractor, Demolition 0806 o Contractor, Earthmoving 0807 o Contractor, Electrical 0808 o Contractor, Elevator 0809 o Contractor, Fencing 0810 o Contractor, Flooring 0811 o Contractor, General