BIDDER'S MAILING LIST APPLICATION

Revised September 29, 2009

Anderson County Purchasing Department
100 N. Main Street Room 214 or 218
Clinton, TN 37716-3687
Phone: (865) 457-6251 Fax: (865) 457-6252
Email: purchasing@andersontn.org
Website: http://andersontn.org/purchasing.html
(Copies of bids can be printed directly from website)

Company Information

Name of Company:
Owner's Name:
Taxpayer ID:
Type of Business:	Other type:

Bid Representative Information

Bid Representative Name:

E-Mail Address:

Bid Packet Mailing Address:

City:

State: Zip:

Telephone:

() -

Extension:

Fax:

() -

Company Website Address:

Emergency Contact Information

In order for Anderson County to be able to reach it's vendors in the case of an emergency, we are requesting the following information. A total of two (2) Emergency After-Hours Contact Names and Cellular Phone Numbers:

(1) Name:

Cell Phone Number:

() -

(2) Name:

Cell Phone Number:

() -

Remittance Information

Remittance Address for Purchase Orders

Street, and apt./ suite no


City	State	ZIP Code

() -

Area Code & Phone Number

() -

Area Code & Fax Number

Remittance Address for Checks

Street, and apt./ suite no


City	State	ZIP Code

() -

Area Code & Phone Number

() -

Area Code & Fax Number

Are you a current employee of Anderson County Government, including all departments and branches?

Yes No If so, what department?

Job Title:

If you are an Anderson County Employee, provide names and telephone numbers of two other companies that you have provided this service or product within the last 12 months.

License and Bonding Information

Do you have a current Business License in the State of Tennessee? Yes No

State of Tennessee Business License Number: Expiration Date:

/ /

What Tennessee County: (**Copy of Business License must be provided**)

State of Tennessee Contractor's License Number (reference T.C.A. 62-6-119):

License Type:

Expiration Date:

/ /

(**Copy of Contractors License must be provided**)

Are you Bonded and Insured? Yes No

Name of Insurer: (**Copy of Certificate of Liability Insurance must be provided**)

General Information

Vendors interested in being added to the Anderson County bidder's database must complete this application indicating the specific items or services to be supplied. Application can be completed online or application can be downloaded and returned by fax, email or U. S. mail to the Anderson County Purchasing Department. Bidder's Mailing List Applications MUST be received by Anderson County Purchasing, ten (10) Calendar days prior to the date bids are issued to bidders, otherwise it is the vendors responsibility to obtain bid information from the Purchasing Department or county website. Failure to respond to Invitations for Bids, Requests for Proposals, or Requests for Quotations will be understood by Anderson County to indicate lack of interest and may result in removal of the vendor's name from the bidder's database. Please notify the Anderson County Purchasing Department at purchasing@andersontn.org immediately of any changes. This includes change of name, address or telephone number, and addition or deletion of items you are interested in supplying. Anderson County Government requires all vendors to submit and maintain Certificates of Liability Insurance prior to the award of bids, proposals and contracts.

Information about the person completing this form:
Name:		Title:		Date:	09/07/2010

I certify that the information supplied herein is correct

Thank you for taking the time to complete our Bidder's Mailing List Application. Once your information has been entered into our system we cannot guarantee that you will receive all bid proposals that are pertinent to your business, due to the high volume of businesses that are in our database. However, all of our current bids are listed on our website http://andersontn.org/purchasing.html. In addition a bulletin board is located outside of the Purchasing Department, room 214 at the Courthouse where we post all of the current bids and you can always call our office to inquire about bids. We look forward to doing business with you.