PacifiCorp

[Pages:5]PacifiCorp

Vendor Registration Form

Return Completed Registration Form To:

PacifiCorp Procurement Attention: Vendor Administration Coordinator 825 NE Multnomah Street, Suite 1800 Portland, Oregon 97232

Email: newsupplier@

Please Note:

1. Registration forms without a signature will not be processed

2. Incomplete registration forms will not be processed 3. Provide signed copy of W-8 or W-9 Form 4. A company work history is required

Please complete this form in detail using additional sheets as necessary. Catalogs/Brochures may be submitted as supplemental information.

Legal Business Name:

(MUST MATCH FEDERAL TAX IDENTIFICATION NUMBER)

Contact Name/Title: Contact E-Mail Address:

Business Address:

STREET ADDRESS

CITY

STATE

COUNTRY

ZIP CODE

Mailing Address:

(IF DIFFERENT THAN ABOVE)

ADDRESS

CITY

STATE

COUNTRY

ZIP CODE

Remit to Address:

(ADDRESS/LOCK BOX #)

ADDRESS

CITY

STATE

COUNTRY

ZIP CODE

Phone/FAX Numbers: Internet URL:

( )

AREA CODE PHONE NUMBER

( )

AREA CODE FAX NUMBER

Federal Tax Identification Number:

Please provide a signed copy of your W-8 or W-9, whichever form is applicable (Request for Taxpayer Identification Number and Certification form)

Are there any current or previous employees of PacifiCorp that are employees, officers, or principle stockholders in your company? Yes No

If yes, please list their names and positions within your company:

Are you an affiliate of Berkshire Hathaway or Berkshire Hathaway Energy Company? Yes No

If yes, please explain:

Are you a member of Veriforce? (If a contract is awarded, your company may need to join Veriforce, but it is not required as part of the registration process. You will be notified at a later point). Yes No

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SECTION 2:

Company Structure and Financial Structure

Sole Proprietor

Partnership

Corporation

Affiliate

LLC

Joint Venture

Subsidiary

Non-Profit

Division of

Year Established:

Number of Employees:

State of Incorporation:

Dunn & Bradstreet Number: Dunn & Bradstreet Rating:

Stock Symbol:

Parent Company Name and Incorporated Address:

FINANCIAL DATA

Please indicate your gross annual sales for the last three years. The most recent year is mandatory.

$

Year

$

Year

$

Year

BUSINESS CLASSIFICATION

Are you a certified diversity enterprise? YES NO

*If Yes, please indicate which diversity classifications apply:

Gender

Race/Ethnicity (If more than one applies, please mark multiple entries)

Service Disabled Veteran

LGBT

Female

American Indian/Alaskan Native

Yes

Yes

Male

Asian

No

No

Other, please specify below

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

*If Yes, which agency or organization issued you the certification?

Please attach your certification.

BUSINESS INFORMATION

Have you performed work for, or supplied material to PacifiCorp, its parent company Berkshire Hathaway Energy Company or its

affiliates?

YES

NO

If yes, provide list on an attached sheet and provide your PacifiCorp or Berkshire Hathaway Energy Company or affiliate vendor ID number(s):

FOREIGN VENDORS

Are you a foreign vendor providing services in the United States? YES NO

*If yes, please provide your U.S. Tax ID number and a copy of your W-8 form.

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SECTION 3:

Indicate geographical areas of business coverage, listing the primary branch location that will support the following states:

Oregon

Branch Location(s):

Washington Branch Location(s):

California Branch Location(s):

Idaho

Branch Location(s):

Utah

Branch Location(s):

Wyoming Branch Location(s):

Work History

? List the projects completed under the company's present legal name within the last two (2) years for each of the types of work and/or services selected. Attach a separate listing for each type of service (boiler overhauls, balance of plant work, turbine valves, etc. (If required, attach additional information using the format shown below

Type of Work Performed

Client Address Contact Phone

Location of Job

Contract Value

Start/Complete Date(s)

Safety Does your company have a formal safety program? YES NO

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SECTION 4:

Please check all categories that you provide:

Batteries Bearings Belts Bird Deterrent supplies Building Supplies Cable & Conductor Capacitors Chemicals, Water Treatment Circuit Breakers Compressors Condensers Construction Products Control Cabinets Control instrumentation Cross Arms, Steel/Wood Distribution Structures Doors Electrical Supplies Fencing Materials Filters, Air, Water & Oil Fire Protection Equipment & Supplies

Applications Consulting

Forklifts Freight& Trucking Services Fuel Oil & Lubricants

Asphalt/Paving/Gravel Services Caterings/Food Services Circuit Breaker Maintenance Crane Services Equipment Rental Services Fabrication Services Fencing Installation & Repair Hazmat Remediation Hydro blasting Services Inspection Services

Advertising Services Architectural Services Audio Visual Services Civil Electrical Engineering Design & Drafting

Goods & Materials Fire Protection Equipment & Supplies Gear Boxes Generators Hardware, Miscellaneous Hardware, Pole Line Hose & Hose Fittings HVAC Equipment and Supplies Ice Machines Industrial Supplies Instruments Insulators Janitorial Supplies Lifting & Rigging Equipment Lighting/Fixtures & Supplies Locks Maintenance, Repair and Operations Supplies Manholes Material Handling Equipment & Supplies Metal Buildings Meters Motors

Information Technology Hardware & Infrastructure Office Equipment

Transportation Third Party Logistics Services Tires Vehicle, Filters Vehicle Repairs

General Services Insulation Services Janitorial Services Machine Shop Services Pest Control Services Plumbing Services Pressure Washing Services Protective Coating Services Pump Repair Services Road Maintenance Services

Professional Services Environmental Consultant Services Financial Services Geotechnical Consulting Services Legal Services Lobbyist Services Mechanical

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Office Equipment/Supplies/Furniture Oil Water Separators Pipe Products Distributor Pipe, Valves & Fittings, Plastic/Steel Plumbing Heaters & Supplies Poles, Concrete/Fiberglass/Steel/Wood Pumps Rectifiers Relay Boards Roofing/Siding/Gutter Supplies Safety, Protective Equipment/Clothing Scaffolding Signage Steel Structures Switches/Switchgear Transformers, Power & Distribution Turbines, Gas/Hydro/Steam/Wind Uninterruptable Power Supply Welding Gases & Supplies Windows Other __________________________

Telecom Other ___________________________

Vehicle, Parts Vehicle, Rentals Vehicles, Light/Medium Duty/Utility Other __________________________

Security Services Surveying & Mapping Tank Cleaning and Repair Services Traffic Control Services Vegetation Management Services Water Craft Repairs Water Treatment Services Weed Abatement Services Welding Services Other _________________________

Other Professional Services Photographic Services Project Management Services Real Estate Services Safety Consultant Services Staff Augmentation Services

Building & Facility Services Building Repair Services Electrician Services Elevator Services Fencing Installation & Repair Floor Covering Services

Ash Handling Systems & Supplies Ash Ponds Backflow Preventer Services Boiler Chemicals Boiler Tubing Coal Handling Equipment & Supplies Condensate Systems & Supplies Construction Services, Balance of Plant

Helicopter Services Line Repair Services Locating Services

Facility Services HVAC Services Interior Remodeling Services Janitorial Services Landscaping Services Overhead Door Services Painting Services

Power Generation - Specialty Goods and Services Conveyor Belts & Suppliers Cooling Towers & Supplies Emission Control Systems & Supplies Gate Services Generator Services Marine Diving Services Marine Dredging Services Marine, Booms and Deployment

Transmission & Distribution Specialty Services Pole Test and Treat Services Right of Way Services Street Light Maintenance Services

Paving Services Plumbing Services Roofing Services Snow Removal Services Other ______________________

Mining, Explosives & deslagging Heavy Equipment Oil Water Separator Services Power Plant Overhaul Services Precipitator and/or scrubbers Retention Ponds/Drainage Wind Operations &Maintenance Services Other ________________________

Substation Construction Services Vegetation Management Services Other ________________________

Please summarize below how your organization can provide value to PacifiCorp.

I ACKNOWLEDGE AND REPRESENT THAT THE INFORMATION FURNISHED IS COMPLETE AND FACTUAL

SIGNATURE Printed name

TITLE

Printed Title

mm/dd/yy DATE

NOTE: The box above must be filled out and signed (or electronically signed) and dated or the vendor registration form will be deemed invalid.

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