FED. EMPLOYER IDENTIFICATION NO. - (Employer Identification #) COMPLETE THIS SECTION WITH CHECK REMITTANCE ADDRESS AS IT APPEARS ON INVOICES: REMIT TO ADDRESS: STREET / PO BOX: CITY, STATE, ZIP: Participation in this section is voluntary. You are not required to complete this section to become a registered vendor. The information below will in no way affect the vendor registration process and its sole purpose is to collect statistical data on those vendors doing business with NCDOT. If you choose to participate, circle the answer that best fits your firm’s group definition. What is your firm’s ethnicity? (Prefer Not To Answer, African American, Native American, Caucasian American, Asian American, Hispanic American, Asian-Indian American, Other: ) What is your firm’s gender? (Prefer Not to Answer,Male, Female) Disabled-Owned Business? (Prefer Not to Answer, Yes, No) IRS Certification Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. person (including a U.S. resident alien). The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. For complete certification instructions please see IRS FORM W-9 at xxxx://xxx.xxx.xxx/pub/irs-pdf/fw9.pdf . NAME (Print or Type) TITLE (Print or Type) SIGNATURE (Typed or DocuSigned signatures will not be accepted) DATE PHONE NUMBER EMAIL To avoid payment delays, completed forms should be returned promptly to: NC Department of Transportation Fiscal /Commercial Accounts 0000 Xxxx Xxxxxxx Xxxxxx, Xxxxxxx, Xxxxx Xxxxxxxx 00000-0000 xx@xxxxx.xxx FAX (000) 000-0000 CONTRACTOR DATA Report any changes in this data immediately to the Right of Way Agent. Corporate Status (Check only one.) License Number: __________________ Dated: _______________ ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Name and title of person authorized to execute this agreement ________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____ Name of individual authorized to answer questions concerning the information contained herein: Name ___________________________________ Telephone No. __(_____)________________________ Name, address, and telephone number of designated management person to contact after award of contract: __________________________________________________________________________________________ Telephone Numbers: (Please put all numbers that are available to you.) Office: ___________________ Cell: _____________________ Pager: ___________________ SUBCONTRACTOR DATA Report any changes in this data immediately to the Right of Way Agent. Corporate Status (Check only one.) ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____
Appears in 3 contracts
Samples: Property Management Agreement, Property Management Agreement, Property Management Agreement
FED. EMPLOYER IDENTIFICATION NO. - (Employer Identification #) COMPLETE THIS SECTION WITH CHECK REMITTANCE ADDRESS AS IT APPEARS ON INVOICES: REMIT TO ADDRESS: STREET / PO BOX: CITY, STATE, ZIP: Participation in this section is voluntary. You are not required to complete this section to become a registered vendor. The information below will in no way affect the vendor registration process and its sole purpose is to collect statistical data on those vendors doing business with NCDOT. If you choose to participate, circle the answer that best fits your firm’s group definition. What is your firm’s ethnicity? (Prefer Not To Answer, African American, Native American, Caucasian American, Asian American, Hispanic American, Asian-Indian American, Other: ) What is your firm’s gender? (Prefer Not to Answer,Male, Female) Disabled-Owned Business? (Prefer Not to Answer, Yes, No) IRS Certification Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. person (including a U.S. resident alien). The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. For complete certification instructions please see IRS FORM W-9 at xxxx://xxx.xxx.xxx/pub/irs-pdf/fw9.pdf . NAME (Print or Type) TITLE (Print or Type) SIGNATURE (Typed or DocuSigned signatures will not be accepted) DATE PHONE NUMBER EMAIL To avoid payment delays, completed forms should be returned promptly to: NC Department of Transportation Fiscal /Commercial Accounts 0000 Xxxx Xxxxxxx Xxxxxx1514 Mail Service Center / Raleigh, Xxxxxxx, Xxxxx Xxxxxxxx North Carolina 00000-0000 xx@xxxxx.xxx FAX (000) 000-0000 CONTRACTOR DATA Report any changes in this data immediately to the Right of Way Agent. Corporate Status (Check only one.) License Number: __________________ Dated: _______________ ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Name and title of person authorized to execute this agreement ________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____ Name of individual authorized to answer questions concerning the information contained herein: Name ___________________________________ Telephone No. __(_____)________________________ Name, address, and telephone number of designated management person to contact after award of contract: __________________________________________________________________________________________ Telephone Numbers: (Please put all numbers that are available to you.) Office: ___________________ Cell: _____________________ Pager: ___________________ SUBCONTRACTOR DATA Report any changes in this data immediately to the Right of Way Agent. Corporate Status (Check only one.) ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____
Appears in 2 contracts
Samples: connect.ncdot.gov, connect.ncdot.gov
FED. EMPLOYER IDENTIFICATION NO. - (Employer Identification #) COMPLETE THIS SECTION WITH CHECK REMITTANCE ADDRESS AS IT APPEARS ON INVOICES: REMIT TO ADDRESS: STREET / PO BOX: CITYEX, STATE, ZIP: Participation in this section is voluntary. You are not required to complete this section to become a registered vendor. The information below will in no way affect the vendor registration process and its sole purpose is to collect statistical data on those vendors doing business with NCDOT. If you choose to participate, circle the answer that best fits your firm’s group definition. What is your firm’s ethnicity? (Prefer Not To Answer, African American, Native American, Caucasian American, Asian American, Hispanic American, Asian-Indian American, Other: ) What is your firm’s gender? (Prefer Not to Answer,Male, Female) Disabled-Owned Business? (Prefer Not to Answer, Yes, No) IRS Certification Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification and I am not subject to backup withholding because: (a) I am exempt from backup withholdingUPS, or (b) USPS I have not been notified by the IRS CERTIFY that I am subject to backup withholding as a result the actual owner of a failure to report all interest or dividendsthe dog, or (c) the IRS has notified me that I am no longer subject the duly authorized agent of the actual owner whose name I have entered above. In consideration of the acceptance of this entry, I (we) agree to backup withholdingabide by the rules and regulations of The American Kennel Club in effect at the time of this event, and by any additional rules and regulations appearing in the premium list for this event, and further agree to be bound by the "Agreement" printed on the reverse side of this entry form. I am (we) certify and represent that the dog entered is not a U.S. person hazard to persons or other dogs. This entry is submitted for acceptance on the foregoing representation and Agreement. I (we) agree to conduct myself (ourselves) in accordance with all such Rules and Regulations (including all provisions applying to discipline) and to abide by any decisions made in accord with them. I (we) certify and represent that the dog entered is not a U.S. resident alien)hazard to persons or other dogs. SIGNATURE of owner or his agent duly authorized to make this entry TELEPHONE# EMAIL SHOW SITE Sorry . . . parking spaces are not available for RV's at these trials. DIRECTIONS TO ST. XXXX DOG TRAINING CLUB From the North: Take 1-94 to Hwy 52. Turn south on Xxx 00 to Southview Blvd. Exit left onto Southview to stop sign. Turn right at the stop sign (you’ll still be on Southview) to Southview Shopping Center (between 12th & 13th Ave.) St Xxxx Dog Training Club is located between Synders drug and Knowlans. Xxxxxx Anytim Fitness SOUTHVIEW BLVD. 10,500 VPD 3RD ST. S.. 10,500 VPD (2005) 12th AVE S. 3,500 VPD (2005) RIBBON AND ROSETTE PRIZES First Place Blue Ribbon Second Place Red Ribbon Third Place Yellow Ribbon Fourth Place White Ribbon Highest Scoring Dog in Regular Classes Blue & Gold Rosette Highest Combined Score in Open B & Utility Blue & Green Rosette Each dog with a Qualifying Score in a Regular Obedience Class Dark Green Ribbon AWARDS OBEDIENCE TRIAL "Dog" when applied here means either sex. A dark green qualifying ribbon will be awarded to each dog attaining a qualifying score. Unless otherwise indicated, all ribbons, rosettes, trophies and awards are offered by the St. Xxxx Dog Training Club, Inc. St Xxxx Dog Training Club will offer a NEW TITLE Rosette to each dog/handler team earning a new title at these trials. HIGHEST SCORING DOG IN REGULAR CLASSES $50.00 Cash and Rosette offered by St. Xxxx Dog Training Club, Inc. HIGHEST COMBINED SCORING DOG IN OPEN B & UTILITY $50.00 Cash and Rosette offered by St. Xxxx Dog Training Club, Inc. First - Fourth Places . . . in all regular & optional titling classes Dog Treats FOR ALL TRIALS . . . THE CLUB, RESERVES THE RIGHT to substitute trophies with ones of equal or greater value. N 13th AVE S. 3,500 VPD (2005) 13th AVE.—no parking on west side of street. Parking on east (closer) side ok. NOTE: NEW PARKING PLAN. No parking in the two closest aisles, in front of Knowlan’s Grocery Store Entrance all the way out to the curb, or in front of the Dollar Store. Parking is allowed behind the building. SHOW SITE HOURS Please refer to your Judging Program for exact rings times and class order or visit xxx.xxxxxxxxxxxxxxxx.xxx for news! The IRS does building will be open from 7:00 AM on Friday, January 6, 2012 for exhibitors to set-up crates and equipment. ACCOMMODATIONS By listing the following hotels/motels, there is not require your consent to any provision of this document other than the certifications required to avoid backup withholdingcertainty that dogs will be accepted in rooms. For complete certification instructions please see IRS FORM W-9 at xxxx://xxx.xxx.xxx/pub/irs-pdf/fw9.pdf Please ask and verify pet policy when making reservations. NAME Red Roof Inn Woodbury (Print or Type) TITLE (Print or Type) SIGNATURE (Typed or DocuSigned signatures will not be dog accepted) DATE PHONE NUMBER EMAIL To avoid payment delaysXxxx 00 - X-000 & Xxxxxx Xxxxx Xxxx - Xxxxxxxx, completed forms should be returned promptly to: NC Department of Transportation Fiscal /Commercial Accounts 0000 Xxxx Xxxxxxx Xxxxxx, Xxxxxxx, Xxxxx Xxxxxxxx 00000-0000 xx@xxxxx.xxx FAX (000XX . 0-(000) 000-0000 CONTRACTOR DATA Report any changes in this data immediately to the Right or 000-000-0000 Holiday Inn Express - Woodbury (small dogs welcome) Exit 251 - I-94 - Woodbury, MN 000-000-0000 Excel Inn of Way AgentSt. Xxxx (small dogs welcome) X-00 & Xxxxx Xxxx Xxxxxx - Xxxxxxxxx, XX 651-771-5566 Xxxxxxx Xxx - Xxxxxxx X-000 & Cty. Corporate Status (Check only one.) License Number: __________________ Dated: _______________ ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship10 - Oakdale, partnership, or LLC) __________________________________________________________________________________________ Name and title of person authorized to execute this agreement ________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____ Name of individual authorized to answer questions concerning the information contained herein: Name ___________________________________ Telephone No. __(_____)________________________ Name, address, and telephone number of designated management person to contact after award of contract: __________________________________________________________________________________________ Telephone Numbers: (Please put all numbers that are available to you.) Office: ___________________ Cell: _____________________ Pager: ___________________ SUBCONTRACTOR DATA Report any changes in this data immediately to the Right of Way Agent. Corporate Status (Check only one.) ____ Corporation _____ Sole Proprietorship _____Partnership ______LLC Company Name (or name in which it does business if sole proprietorship, partnership, or LLC) __________________________________________________________________________________________ Address of Company Name____________________________________________________________________ Business Phone Number_(_____)__________________ 24 Hr./Pager # _____________________ Answering Service Local/Toll Free Number __________________________________________________ Facsimile (Fax) Number___________________ Email Address________________________________ N. C. Corporate ID No. __________________ Federal I.D. No. (EIN) ____________________________ Indicate if other than Large Business: (As defined under Special Interest Groups Definition below) Minority Owned ____ Woman Owned ____ Handicap Owned ____ Disabled Owned ____ Small Business____MN 651-578-8466
Appears in 1 contract
Samples: www.dogshowsbydesign.com
