Government of New York



ATTACHMENT 9AUTHORIZED DEALER/DISTRIBUTOR INFORMATION(for ordering and contract administration purposes)CONTRACTOR INFORMATIONCompany Name: FORMTEXT ?????NYS Contract Number: FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR/ INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ?????DEALER/DISTRIBUTOR INFORMATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????MWBE and/or SDVOB Certification: ? NYS Certified Women Owned ? NYS Certified Minority Owned ? SDVOBSBE: ?NYS Small Business Enterprise (self-identified)Is Company an Authorized Dealer or Distributor?? Dealer? DistributorQualifying Criteria Applicable to this Dealer/Distributor: FORMTEXT ?????Restrictions Applicable to this Dealer/Distributor (if any): FORMTEXT ????? ................
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