This questionnaire has been developed to collect information from contractors/suppliers seeking to do business with BJWSA.

* Is this an initial application?   Yes   No         * Is this a revision?   Yes   No

* Does this business now, or has it in the past 10 years, used an EIN, SSN, Trade Name or abbreviation other than those given in the above question?
Yes   No

If YES, please provide details and explain

* Has this business changed address(es) in the past five years?
Yes   No

If YES, please provide all previous addresses

* Type of Organization

* Type of Business

Please check one business type and indicate alternates, if necessary. Enter your most appropriate vendor code(s) beside your business type. Download the vendor code list to find your vendor code(s).

* Has this business been certified by a government entity (SBA, OSMBA, etc.) as a Minority Business, Women-Owned Business, Disadvantaged Business or Small Business Enterprise?
Yes   No

* Does the business perform outreach efforts to any of these enterprises to perform subcontracted work?
Yes   No

* Does the business own, rent, or lease office facilities?
Own   Rent   Lease

If owned or leased, please provide information for building owner/landlord & where sited:

* Will this business use or occupy any real property, other than the addresses listed in response to question 1, to carry out any terms of any contract you may receive from BJWSA?
Yes   No

If YES, please provide details and explain:

Contractor/Supplier Certification

I, the undersigned, certify and declare that I have read all of the foregoing answers to this qualification questionnaire and know their contents. The matters stated in the questionnaire answers are true of my own knowledge and belief, except as to those matters stated on information and belief, and as to those matters I believe them to be true.