Free DT1025MCSS - Wisconsin

Wisconsin Department of Transportation
DT1025 5/2005

Send To: WIsconsin Department of Transportation
Purchasing - Room 751 PO Box 7396 Madison WI 53707-7396 LEGAL NAME - REQUIRED - (As recorded with the IRS)

VENDOR REGISTRATION APPLICATION
(Substitute W9) Business Name (DBA)
TIN No (FEIN OR SOCIAL SECURITY NO., not both) (1) FEIN:

OR
(2) SSN:

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SOLICITATION STREET ADDRESS (2)

Please enter information below captions.
GENERAL STREET ADDRESS (1)

City

County

State (2 digit)

ZIP Code (9-digit)

City

County

State (2 digit)

ZIP Code (9-digit)

CONTACT PERSON

Position

CONTACT PERSON

Position

Area Code - Telephone Number

800 Number

FAX Number

Area Code - Telephone Number

800 Number

FAX Number

ORDER STREET ADDRESS (3)

PAYEE STREET ADDRESS (4)

City

County

State (2 digit)

ZIP Code (9-digit)

City

County

State (2 digit)

ZIP Code (9-digit)

CONTACT PERSON

Position

CONTACT PERSON

Position

Area Code - Telephone Number

800 Number

FAX Number

Area Code - Telephone Number

800 Number

FAX Number

BUSINESS TYPE
(Check appropriate)

__(1) Manufacturer __(5) Consulting

__(2) Retailer __(6) Construction

__(3) Wholesaler __(7) Printer

__(4) Service __(8) Work Center

ORGANIZATION TYPE (Check and complete appropriate) __(C) Corporation - Incorporated State __________, Date of Incorporation ___________________ __Yes __No Is corporation in the business of providing health care/medical services? __(P) Partnership __(LP) Limited Liability Company - Partnership __(LC) Limited Liability Company - Corporation __(S) Sole Proprietor __(I) Individual __(G) Government Entity __(M) WI Municipality __(W) WI State Agency __(O) Other (Specify): ___________________________________________________ How long in present business: ______ years _____ months. Average number of full time employees: _____
BUSINESS OWNERSHIP (Check appropriate) A. Female Owned __(W) Small __(X) Large B. Minority Female Owned __(WA) Small __(WD) Large C. Minority Owned __(MA) Small __ (MD) Large D. Non-Minority Owned __(NS) Small __(NL) Large

RACIAL/ETHNICITY (Check appropriate) __(A) Asian __(B) Black/African American __(W) Native Hawiian/Polynesian __(O) Other - Specify: _____________________________________________ ANNUAL SALES (GROSS REVENUE) (Check appropriate)

__(H) Hispanic __(C) Caucasian

__(I) Native American/Indian

__(2) Below $100,001 __(4) $500,001 - $1,500,000 __(6) $5,000,001 - $10,000,000

__(3) $100,001 - $500,000 __(5) $1,500,001 - $5,000,000 __(7) More than $10,000,000

Certification Instructions: You must cross out item (2) below if you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. I certify that: (1) The number listed on this form is my correct taxpayer identification number and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends; or (c) The IRS has notified me that I am no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest paid, the acquisition of abandonment of secured property, contribution to an individual retirement arrangement (IRA), and payments other than interest and dividends). (3) I am a U.S. person (including a U.S. resident alien).

(Company E-Mail Address)

(Print Applicant Name/Title)

X
(Company Internet URL) (Applicant Signature) (Date Signed)

CODING FOR GOODS OR SERVICES TO BE PROVIDED BY YOUR FIRM Select from the Commodity Code Directory those goods or services for which your firm wishes to receive Invitations to Bid and requests for Quotation. Enter the corresponding 5-digit Class/Subclass (C/SC) Codes. Include preceding zeroes (3-digit Class plus 2-digit Subclass) in the space provided below. Attach an extra sheet if needed.
C/SC CODE C/SC CODE C-SC CODE C/SC

NOTE: It is important that you evaluate all commodity codes and select only those which most accurately describe the goods or services your firm provides. Three-digit classes 005 through 898 list commodities, while all 900 series classes are services. Do not send brochures or product catalogs with this application.
C/SC CODE C/SC CODE C/SC CODE

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Do you desire to Bid statewide in Wisconsin? Yes
__ __ __ __ __ __ __ __ __ __ __ __ 1 2 3 4 5 6 7 8 9 10 11 12 Adams Ashland Barron Bayfield Brown Buffalo Burnett Calumet Chippewa Clark Columbia Crawford

No - (then check only those counties below for which you desire to bid).
__ __ __ __ __ __ __ __ __ __ __ __ 13 14 15 16 17 18 19 20 21 22 23 24 Dane Dodge Door Douglas Dunn Eau Claire Florence Fond du Lac Forest Grant Green Green Lake __ __ __ __ __ __ __ __ __ __ __ __ 25 26 27 28 29 30 31 32 33 34 35 36 Iowa Iron Jackson Jefferson Juneau Kenosha Kewaunee La Crosse Lafayette Langlade Lincoln Manitowoc __ __ __ __ __ __ __ __ __ __ __ __ 37 38 39 73 40 41 42 43 44 45 46 47 Marathon Marinette Marquette Menominee Milwaukee Monroe Oconto Oneida Outagamie Ozaukee Pepin Pierce __ __ __ __ __ __ __ __ __ __ __ __ 48 49 50 51 52 53 54 55 56 57 58 59 Polk Portage Price Racine Richland Rock Rusk St. Croix Sauk Sawyer Shawano Sheboygan __ __ __ __ __ __ __ __ __ __ __ __ 60 61 62 63 64 65 66 67 68 69 70 71 Taylor Trempealeau Vernon Vilas Walworth Washburn Washington Waukesha Waupaca Waushara Winnebago Wood