This Supplier Application is required for all suppliers wishing to conduct business with Grand Rapids Community College. You must have JavaScript enabled to use this form. Company Information Company Name ID Number ID Type Social Security Number Federal ID Organization Type Individual Partnership Corporation Limited Liability Corporation (LLC) Parent Company Website Email Phone Fax Mailing Address Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Billing Address Billing address is different from mailing address Billing address is different from mailing address Billing Address Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Primary Contact First Name Last Name Job Title Email Phone Cellphone Secondary Contact Add Secondary Contact Add Secondary Contact Secondary Contact First Name Last Name Job Title Email Phone Cellphone Supplier Questions Do you accept Procurement Cards? Yes No Do you accept electronic payments?" Yes No Standard Payment Terms Prompt Pay Discount Standard Delivery Time Certifications Michigan Department of Transportation (MDOT) Michigan Minority Business Development Council (MMBDC) City of Grand Rapids Women's Business Enterprise National Council (WBENC) Other MDOT Certifications Certificate Number Expiration Date MMBDC Certifications Certificate Number Expiration Date City of Grand Rapids Micro-Local Business Enterprise Certificate Number Expiration Date Women's Business Enterprise National Council (WBENC) Certifications Certificate Number Expiration Date Other Other Certifications Please list any other certifications For Reporting Purposes Ownership Percentage Women Ownership % Minority Ownership % Disabled Ownership % Veterans Ownership % Please list percentages. Enter 0% if not applicable. Ethnicity Black/African American American Indian/Alaskan Native Asian Hispanic/Latino Decline to answer Other Other Are you a small business? Yes No Are you located within the GRCC District? Yes No Commodity Please check the appropriate NAICS commodity code. NAICS Code 11 – Agriculture, Forestry, Fishing and Hunting 21 – Mining 22 – Utilities 23 – Construction 31-33 – Manufacturing 42 – Wholesale Trade 44-45 – Retail Trade 48-49 – Transportation and Warehousing 51 – Information 52 – Finance and Insurance 53 – Real Estate and Rental and Leasing 54 – Professional, Scientific and Technical Services 55 – Management of Companies and Enterprises 56 – Administrative and Support, Waste Management and Remediation Services 61 – Educational Services 62 – Health Care and Social Assistance 71 – Arts, Entertainment and Recreation 72 – Accommodation and Foodservices 81 – Other Services (except Public Administration) 92 – Public Administration 99 – Unclassified Establishments Category Manufacturer or Producer Wholesaler Retailer Manufacturer's Agent Distributor Service Establishment Signature Name Job Title Today's Date Signature I confirm that all the information submitted here is accurate. I confirm that all the information submitted here is accurate. Signature of person authorized to sign this application.