Vendor Application County of Alameda

Request

Add New Vendor

Add new doing-business-as (DBA) name for existing vendor

Add new address for existing vendor

Change Name DBA Address for existing vendor (Check One)

Other

Vendor Information

Full Legal Business Name:

DBA Name:

Type of Entity:	Individual	Sole Proprietor	Partnership
	Corporation	Tax-Exempted	Government or Trust

Check the boxes that apply to Alameda County payments you may receive:
Goods Only	Goods & Services	Rents/Leases	Rents/Leases paid to you as the agent
Medical Services	Legal Services	Other Services (describe)
Settlement, Judgment, Refunds (If checked, skip Composition of Ownership section below)
Court Appointed Services (If checked, skip Composition of Ownership section below)

*Federal Tax ID Number:

PO Box/Street Address:

City:

State:

Zip:

Is your business located in Alameda County? Yes No If yes, how long? Yr. Mo.

Vendor Contact's Name:

Contact's Telephone:

FAX:

Toll Free:

Vendor E-mail address:

Composition of Ownership - This is a Required Section*
Are you a publicly traded entity, a public school, or a government? Yes No Are you a non-profit or a church? Yes No If "Yes" to one of the above, skip Ethnicity and Gender below. The collection of ethnicity and gender data is for statistical and demographic purpose only.
Please check the ONE most applicable category in EACH column

Ethnicity
African American or Black (greater than 50%)	Hispanic or Latino (greater than 50%)
American Indian or Alaskan Native (greater than 50%)	Native Hawaiian/Pacific Islander (greater than 50%)
Asian (greater than 50%)	Multi-ethnic minority ownership (greater than 50%)
Caucasian or White (greater than 50%)	Multi-ethnic ownership (50%Minority - 50% Non-Minority)
Filipino (greater than 50%)

Gender
Female (greater than 50% Ownership)	Male (greater than 50% Ownership)

List the Products and/or Services Vendor is interested in providing; include North American Industry Classification System (NAICS) Code
(available at https://eweb1.sba.gov/naics/dsp_naicssearch2.cfm):

Completed By: Title: Date: