POTENTIAL VENDOR INFORMATION
Anyone conducting business with Navarro College must submit the following
documents and information to the purchasing office prior to a contract or
purchase order being issued.
1.
Vendor Information Form
2.
IRS W9 Form
3.
References
4.
Conflict of Interest Questionnaire (required is any relationship exists with
college staff or members of Board of Trustees)
5.
Felony Conviction Notification Form - Please contact our office if you
need this form.
Sole Source Providers must submit a completed Sole Source Provider Form.
Vendors on state contract or part of a state-approved purchasing cooperative
must provide a letter on company letterhead providing names of cooperatives,
state contract numbers, and any other identification numbers necessary to
process a purchase requisition if that information is not provided on the Vendor
Information Form.
All purchases made by Navarro College will be FOB Destination.
All vendors must provide Navarro College with a designated contact person,
telephone number(s), and email address.
Navarro College places all bids on the State of Texas Electronic State Business
Daily at esbd.cpa.state.tx.us/
Navarro College is a member of several purchasing cooperatives. Please
contact the Purchasing department if you are an approved vendor on a
purchasing cooperative in the State of Texas and would like to do business with
Navarro College.
Orders placed without a signed purchase order will not be honored by Navarro
College.
Email susan.hemsworth@navarrocollege.edu for information.
Vendor Information Form
To become a potential vendor and/or to receive bids, please fill out the Vendor Information Form below.
The Vendor Information Form, a current W9, and Conflict of Interest Questionnaire (if applicable) may be
mailed to the Purchasing Department located on the Corsicana Campus at 3200 W. 7
th
Avenue, Corsicana,
Texas 75110 or it can be faxed to (903) 874-4636.
Company Information
Company Name________________________________________________________________
Physical Address_______________________ City __________________ State_____ Zip_____
Mailing Address_______________________ City __________________ State _____ Zip_____
Phone________________________________ Fax_____________________________________
Name of Contact Person______________________________ Title________________________
E-mail Address of Contact Person__________________________________________________
Type of Organization
Do you provide Products _____ Services _____
What type of products/services do you offer __________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please Indicate if Your Company is a member of a Purchasing Cooperative
E & I Yes_____ No_____ If Yes, Provide Contract Number_____________________
TXMAS Yes_____ No_____ If Yes, Provide Contract Number_____________________
BUYBOARD Yes_____ No_____ If Yes, Provide Contract Number_____________________
Other: Yes_____ No_____ If Yes, Provide Name of Co-Op and Contract Number
__________________________________________________________________________________
Vendors Must Disclose:
1. If any of its employees, officers, directors, subcontractors or agents are related to or are members of the board
of trustees or an employee of the district; and
2. If the owner or operator of the company has ever been convicted of, or is currently charged with, a felony.
3. Persons submitting a response to this solicitation must comply with all applicable laws, ordinances and
regulations including the provisions of the State of Texas Government Code Chapter 176. As applicable, the
person submitting the response must complete and submit a Conflict of Interest Questionnaire form CIQ, in a
format approved by the Texas Ethics Commission.
Authorized Signature: ________________________________________ Date: ______________________
Printed Name: _______________________________________________
click to sign
signature
click to edit
Give form to the
requester. Do not
send to the IRS.
Form W-9
Request for Taxpayer
Identification Number and Certification
(Rev. January 2003)
Department of the Treasury
Internal Revenue Service
Name
List account number(s) here (optional)
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Print or type
See
Specific Instructions
on page 2.
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).
However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on
page 3. For other entities, it is your employer identification number (EIN). If you do not have a number,
see How to get a TIN on page 3.
Social security number
or
Requester’s name and address (optional)
Employer identification number
Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number
to enter.
Certification
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
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, and
2.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)
Sign
Here
Signature of
U.S. person
Date
Purpose of Form
Form W-9 (Rev. 1-2003)
Part I
Part II
Business name, if different from above
Cat. No. 10231X
Check appropriate box:
Under penalties of perjury, I certify that:
U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding,
or
3. Claim exemption from backup withholding if you are a
U.S. exempt payee.
Foreign person. If you are a foreign person, use the
appropriate Form W-8 (see Pub. 515, Withholding of Tax on
Nonresident Aliens and Foreign Entities).
3. I am a U.S. person (including a U.S. resident alien).
A person who is required to file an information return with
the IRS, must obtain your correct taxpayer identification
number (TIN) to report, for example, income paid to you, real
estate transactions, mortgage interest you paid, acquisition
or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Individual/
Sole proprietor Corporation Partnership Other
Exempt from backup
withholding
Note: If a requester gives you a form other than Form W-9
to request your TIN, you must use the requester’s form if it is
substantially similar to this Form W-9.
Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual may use the
terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a
provision known as a saving clause.” Exceptions specified
in the saving clause may permit an exemption from tax to
continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax treaty to
claim an exemption from U.S. tax on certain types of income,
you must attach a statement that specifies the following five
items:
1. The treaty country. Generally, this must be the same
treaty under which you claimed exemption from tax as a
nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under
the terms of the treaty article.
Form W-9 (Rev. 1-2003) Page 2
Sole proprietor. Enter your individual name as shown on
your social security card on the Name line. You may enter
your business, trade, or doing business as (DBA) name on
the Business name line.
Other entities. Enter your business name as shown on
required Federal tax documents on the Name line. This
name should match the name shown on the charter or other
legal document creating the entity. You may enter any
business, trade, or DBA name on the Business name line.
If the account is in joint names, list first, and then circle,
the name of the person or entity whose number you entered
in Part I of the form.
Limited liability company (LLC). If you are a single-member
LLC (including a foreign LLC with a domestic owner) that is
disregarded as an entity separate from its owner under
Treasury regulations section 301.7701-3, enter the owners
name on the Name line. Enter the LLCs name on the
Business name line.
Specific Instructions
Name
Exempt From Backup Withholding
Generally, individuals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments, such as
interest and dividends.
5. You do not certify to the requester that you are not
subject to backup withholding under 4 above (for reportable
interest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Civil penalty for false information with respect to
withholding. If you make a false statement with no
reasonable basis that results in no backup withholding, you
are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully
falsifying certifications or affirmations may subject you to
criminal penalties including fines and/or imprisonment.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN
to a requester, you are subject to a penalty of $50 for each
such failure unless your failure is due to reasonable cause
and not to willful neglect.
Misuse of TINs. If the requester discloses or uses TINs in
violation of Federal law, the requester may be subject to civil
and criminal penalties.
If you are an individual, you must generally enter the name
shown on your social security card. However, if you have
changed your last name, for instance, due to marriage
without informing the Social Security Administration of the
name change, enter your first name, the last name shown on
your social security card, and your new last name.
Exempt payees. Backup withholding is not required on any
payments made to the following payees:
1. An organization exempt from tax under section 501(a),
any IRA, or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(f)(2);
2. The United States or any of its agencies or
instrumentalities;
3. A state, the District of Columbia, a possession of the
United States, or any of their political subdivisions or
instrumentalities;
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities; or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup
withholding include:
6. A corporation;
7. A foreign central bank of issue;
8. A dealer in securities or commodities required to register
in the United States, the District of Columbia, or a
possession of the United States;
If you are exempt, enter your name as described above and
check the appropriate box for your status, then check the
Exempt from backup withholding box in the line following
the business name, sign and date the form.
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
3. The IRS tells the requester that you furnished an
incorrect TIN, or
2. You do not certify your TIN when required (see the Part
II instructions on page 4 for details), or
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make
the proper certifications, and report all your taxable interest
and dividends on your tax return.
1. You do not furnish your TIN to the requester, or
What is backup withholding? Persons making certain
payments to you must under certain conditions withhold and
pay to the IRS 30% of such payments (29% after December
31, 2003; 28% after December 31, 2005). This is called
backup withholding. Payments that may be subject to
backup withholding include interest, dividends, broker and
barter exchange transactions, rents, royalties, nonemployee
pay, and certain payments from fishing boat operators. Real
estate transactions are not subject to backup withholding.
Payments you receive will be subject to backup
withholding if:
If you are a nonresident alien or a foreign entity not
subject to backup withholding, give the requester the
appropriate completed Form W-8.
Example. Article 20 of the U.S.-China income tax treaty
allows an exemption from tax for scholarship income
received by a Chinese student temporarily present in the
United States. Under U.S. law, this student will become a
resident alien for tax purposes if his or her stay in the United
States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply
even after the Chinese student becomes a resident alien of
the United States. A Chinese student who qualifies for this
exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on
his or her scholarship or fellowship income would attach to
Form W-9 a statement that includes the information
described above to support that exemption.
Note: You are requested to check the appropriate box for
your status (individual/sole proprietor, corporation, etc.).
Note: If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
Form W-9 (Rev. 1-2003) Page 3
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an
SSN, your TIN is your IRS individual taxpayer identification
number (ITIN). Enter it in the social security number box. If
you do not have an ITIN, see How to get a TIN below.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5,
Application for a Social Security Card, from your local Social
Security Administration office or get this form on-line at
www.ssa.gov/online/ss5.html. You may also get this form
by calling 1-800-772-1213. Use Form W-7, Application for
IRS Individual Taxpayer Identification Number, to apply for an
ITIN, or Form SS-4, Application for Employer Identification
Number, to apply for an EIN. You can get Forms W-7 and
SS-4 from the IRS by calling 1-800-TAX-FORM
(1-800-829-3676) or from the IRS Web Site at www.irs.gov.
If you are asked to complete Form W-9 but do not have a
TIN, write Applied For in the space for the TIN, sign and
date the form, and give it to the requester. For interest and
dividend payments, and certain payments made with respect
to readily tradable instruments, generally you will have 60
days to get a TIN and give it to the requester before you are
subject to backup withholding on payments. The 60-day rule
does not apply to other types of payments. You will be
subject to backup withholding on all such payments until you
provide your TIN to the requester.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that
you use your SSN.
If you are a single-owner LLC that is disregarded as an
entity separate from its owner (see Limited liability
company (LLC) on page 2), enter your SSN (or EIN, if you
have one). If the LLC is a corporation, partnership, etc., enter
the entitys EIN.
Note: See the chart on page 4 for further clarification of
name and TIN combinations.
Note: Writing Applied For means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign
owner must use the appropriate Form W-8.
9. A futures commission merchant registered with the
Commodity Futures Trading Commission;
10. A real estate investment trust;
11. An entity registered at all times during the tax year
under the Investment Company Act of 1940;
12. A common trust fund operated by a bank under
section 584(a);
13. A financial institution;
14. A middleman known in the investment community as a
nominee or custodian; or
15. A trust exempt from tax under section 664 or
described in section 4947.
THEN the payment is exempt
for . . .
If the payment is for . . .
All exempt recipients except
for 9
Interest and dividend payments
Exempt recipients 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Broker transactions
Exempt recipients 1 through 5Barter exchange transactions
and patronage dividends
Generally, exempt recipients
1 through 7
2
Payments over $600 required
to be reported and direct
sales over $5,000
1
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys fees; and payments
for services paid by a Federal executive agency.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.
Form W-9 (Rev. 1-2003) Page 4
What Name and Number To Give the
Requester
Give name and SSN of:For this type of account:
The individual1. Individual
The actual owner of the account
or, if combined funds, the first
individual on the account
1
2. Two or more individuals (joint
account)
The minor
2
3. Custodian account of a minor
(Uniform Gift to Minors Act)
The grantor-trustee
1
4. a. The usual revocable
savings trust (grantor is
also trustee)
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered
active during 1983. You must give your correct TIN, but you
do not have to sign the certification.
The actual owner
1
b. So-called trust account
that is not a legal or valid
trust under state law
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts
considered inactive during 1983. You must sign the
certification or backup withholding will apply. If you are
subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2
in the certification before signing the form.
The owner
3
5. Sole proprietorship or
single-owner LLC
Give name and EIN of:For this type of account:
3. Real estate transactions. You must sign the
certification. You may cross out item 2 of the certification.
A valid trust, estate, or
pension trust
6.
Legal entity
4
4. Other payments. You must give your correct TIN, but
you do not have to sign the certification unless you have
been notified that you have previously given an incorrect TIN.
Other payments include payments made in the course of
the requesters trade or business for rents, royalties, goods
(other than bills for merchandise), medical and health care
services (including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat
crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
The corporationCorporate or LLC electing
corporate status on Form
8832
7.
The organizationAssociation, club, religious,
charitable, educational, or
other tax-exempt organization
8.
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529),
IRA or Archer MSA contributions or distributions, and
pension distributions. You must give your correct TIN, but
you do not have to sign the certification.
The partnershipPartnership or multi-member
LLC
9.
The broker or nomineeA broker or registered
nominee
10.
The public entityAccount with the Department
of Agriculture in the name of
a public entity (such as a
state or local government,
school district, or prison) that
receives agricultural program
payments
11.
Privacy Act Notice
1
List first and circle the name of the person whose number you furnish. If only
one person on a joint account has an SSN, that persons number must be
furnished.
2
Circle the minors name and furnish the minors SSN.
3
You must show your individual name, but you may also enter your
business or DBA name. You may use either your SSN or EIN (if you have
one).
4
List first and circle the name of the legal trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the legal
entity itself is not designated in the account title.)
Note: If no name is circled when more than one name is
listed, the number will be considered to be that of the first
name listed.
Sole proprietorship or
single-owner LLC
The owner
3
12.
Part II. Certification
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt from backup withholding on page 2.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
To establish to the withholding agent that you are a U.S.
person, or resident alien, sign Form W-9. You may be
requested to sign by the withholding agent even if items 1, 3,
and 5 below indicate otherwise.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses the
numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information
to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their
tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce
Federal nontax criminal laws and to combat terrorism.
Signature requirements. Complete the certification as
indicated in 1 through 5 below.
Adopted 06/29/2007
FORM CIQ
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code
by a person who has a business relationship as defined by Section 176.001(1-a) with a local
governmental entity and the person meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental
entity not later than the 7th business day after the date the person becomes aware of facts
that require the statement to be filed. See Section 176.006, Local Government Code.
A person commits an offense if the person knowingly violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not
later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)
Name of person who has a business relationship with local governmental entity.
1
2
3
Date Received
Name of local government officer with whom filer has employment or business relationship.
Name of Officer
This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an
employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional
pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment
income, from the filer of the questionnaire?
Yes No
B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the
direction of the local government officer named in this section AND the taxable income is not received from the local
governmental entity?
Yes No
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local
government officer serves as an officer or director, or holds an ownership of 10 percent or more?
Yes No
D. Describe each employment or business relationship with the local government officer named in this section.
Signature of person doing business with the governmental entity
Date
4