Bidder's Mailing List Application

Office of Business Services

MCC is requesting information that is necessary to accomplish the statutory purpose as outlined under, III. Public Comm. College Act, Ch. 122 pars. 103-27.1. Disclosure of this information is REQUIRED. Failure to provide information will result in this form not being processed.

INSTRUCTIONS: In order to be placed on the College's Bidder Mailing List, the applicant must execute this form in accordance with the instructions shown herein. Applicant must respond to all 20 required questions. If appropriate answer is "same,""not applicable," or "none," applicant shall so state so as to indicate the question has not been overlooked. It is the responsibility of the applicant to notify McHenry County College of any and all changes in the content of this application at the time of the change. Submit form when completed.

Contact Information

(* Required Fields)


Address to which invitations to bid and purchase orders are to be mailed is different from primary address

Address to which payment is to be mailed is different from primary address

If a division of a Corporation, give name and address of Parent Company

Incorporated under the laws of the State of:

Bank Reference

Class Code List

Check here if you sell products produced from recycled materials.

Please place a checkmark by the items you are interested in supplying.


Company Information

In compliance with the Illinois Purchasing Act state the name of each individual having a beneficial interest of more than 7 percent In the bidding enterprise and each Individual, who, together with spouse or minor children, has a beneficial interest of more than 15 percent In the bidding enterprise. (Applies to proprietorships. partnerships, and/or corporations.)

If applicant is a Corporation, the following must be completed:

Are any of the persons listed above Elected Officials, Members of the General Assembly, State Officers, McHenry County College Employees, Illinois State Employees, or the spouse or minor child of such official, assembly member, officer, or employee?

Company Classification

A. " " means a firm that is classified as such by the State of Illinois. (If the applicant's business is a combination of the following, the information should be separated and proportioned accordingly. If in business less than a year, state anticipated dollar figures :)

$

$

$

#

$

B. " " means a business concern which is at least 51 percentum owned by one or more minority persons, or in the case of a corporation, at least 51 percentum of the stock which is owned by one or more minority persons: and the management and daily operations of which are controlled by one or more of the minority individuals who own it.

Minority shall mean a person who is a citizen or lawful permanent resident of the United States and who is: Black, Hispanic, Asian American, or American Indian or Alaskan Native. (For clarification of ethnic categories, contact the Minority and Female Business Enterprise Division of the Illinois Department of Central Management Services.)

Under this definition, this firm is: (check where appropriate)

We reserve the right to verify this information with CMS.

C. "" means a business concern which is at least 51 percentum owned by one or more females, or, in the case of a corporation, at least 51 percentum of the stock which Is owned by one or more females; and the management and daily business operations of which are controlled by one or more of the females who own it.

"Female" shall mean a person who is a citizen or lawful permanent resident of the United States and who is of the female gender. (For clarification of ethnic categories, contact the Minority and Female Business Enterprise Division of the Illinois Department of Central Management Services.)

Under this definition, this firm is: (check where appropriate)

We reserve the right to verify this information with CMS.

D. shall be one which:

  1. complies with Illinois laws governing not-for-profit organizations
  2. is certified as a sheltered workshop by the Wage and Hour Division of the U.S. Department of Labor
  3. meets the IDORS Just Standards for rehabilitation facilities.

Under this definition, this firm is:

E.

F.

G.

Ownership Details

Identify those who own 5 percent or more of the firm's ownership

Name Address Race Gender Years of Ownership Ownership Percentage Voting Percentage

Control of Firm: Identify by name and title (also race and sex for minority and/or female preference) in the firm those individuals (including owners and non-owners) who are responsible for day to day management and policy decision making, including, but not limited to, those with prime responsibility for:


A. Financial Decisions

B. Management

C. Estimating

D. Marketing and Sales

Race

E. Hiring/Firing of Personnel

Race

F. Purchasing

Describe any stock options, or ownership options that are outstanding, and any agreements between owners or between owners and third parties which restrict ownership or control of minority or female owners.

Identify any owner or management official of the named firm who is or has been an employee of another firm that has an ownership interest in or present business relationship with the named firm. Present business relationships include shared space, equipment, financing, or employees as well as both firms having some of the same owners.

Is the firm authorized to do business in the State as well as locally, including all necessary business licenses?


The contractor/vendor certifies that the contractor is not barred from bidding on the contract as a result of a conviction for either bid rigging or bid rotating under article 33E of the criminal code of 1961.

Resolution on Prevailing Wage:

It shall be mandatory for all contractors and subcontractors who are hired by the College to pay all laborers, workmen and mechanics employed by them not less than the general prevailing rate of wages. The Illinois Department of Labor periodically determines what the prevailing wage rate is in various locales throughout the State. Illinois Prevailing Wage Act, June 26, 1941, as amended, being Section 39A-9 of Chapter 48 of the Illinois Revised Statutes, 1977.

Applicant Self-Certification

The undersigned applicant does swear or affirm that:

  1. the information provided in the Bidder's Mailing List Application is true and correct as of the time of signing (NOTE: Any significant additional or modifying information must be submitted to the college at the time of the change),
  2. neither applicant nor any principal officer or employer, so far as is known, is now debarred or declared ineligible by any State agency from bidding or otherwise furnishing goods or services to the State, and
  3. applicant, its officers or employees, have not been convicted of bribery nor attempted bribery of an officer or employee of the State of Illinois, nor have made an admission of guilt of such conduct that is a matter of record.
  4. applicant is an equal opportunity employer and is in compliance with the equal opportunity requirements of state and federal laws and the Regulations Governing Procurement and Bidding at State Systems Universities in Illinois.

Applicant understands that information provided herein may be audited by the State or verified by other means.

Applicant further understands that failure to provide accurate information required by this form may, in accordance with the Illinois Purchasing Act, PA 83-1332, the Regulations Governing Procurement and Bidding at McHenry County College and other laws, result in penalties including but not limited to suspension from doing business with the college, termination of contracts, and loss of profits in appropriate cases.

20175221235424