DEPARTMENT OF ADMINISTRATIVE SERVICES

DIVISION OF BUDGET AND PURCHASING

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ON-LINE VENDOR FORM

Company Name:
Contact Person:
Title:
Number of Employees:
Address:
City/State/Zip:
Phone Number:
Fax Number:
Minority Owned: (51% or more owned and operated by minorities)
Are you a minority registered vendor in New Jersey:
If yes -- NJ Registration Number:
Female Owned: (51% or more owned and operated by a female)
Are you a minority registered vendor in New Jersey:
If yes -- NJ Registration Number:
Does your company have an office located in Atlantic County?
If Yes, please include location:
Does your company currently have any contracts with the State of New Jersey:
If yes, state the commodity and contract number:
State any additional commodity and contract number:
Please list the commodity(ies) or service(s) you are interested in providing to Atlantic County:
Your E-Mail Address: (REQUIRED)

	Atlantic County Government DEPARTMENT OF ADMINISTRATIVE SERVICES