Company Name:  

Address:    City:  

State:      Zip:  

Federal Tax ID or Social Security #:     Annual Gross Receipts of Company:

Year Established:                  Number of Employees: 

Website address:   

Contact Person:           Title:  

Phone #:   Fax #:  E-mail:  

Company Ownership

Sole Proprietorship     Partnership       Corporation      Other (specify)   

Are you a Historically Underutilized Business (HUB)?  Yes  No     If yes, #

(http://www.tbpc.state.tx.us/communities/procurement/prog/hub)

Are you a Disadvantaged Business Enterprise (DBE)?  Yes  No    If yes, #

(http://www.dot.state.tx.us/business/tucpinfo.htm)

List the equipment, supplies, materials and/or services you would like to be on the Vendor/Bid List for:

Check the area(s) you are interested in providing services in:

 Bryan           Livingston            Lufkin            Nacogdoches            The Woodlands

List three references that you have recently provided goods/services for.

Company Name:   

Contact Person:          Phone #:

Address:  City:  State:  ZIP: 

Company Name:   

Contact Person:          Phone #:

Address:  City:  State:  ZIP: 

Company Name:   

Contact Person:          Phone #:

Address:  City:  State:  ZIP: