Service Provider Application

Name of Business(Required)

Email(Required)

Phone(Required)

Business Website

Employer Identification Number (EIN)(Required)

Unified Business Identifier (UBI)(Required)

UEI Number

Also known as a Sam.Gov number. Not required, but if your business has one we need to check it for debarments if the work contracted is federally funded.

How long have you been in business?(Required)

What is the maximum dollar value of work that your firm is capable of undertaking?(Required)

Other Service Provided:(Required)

Please list areas of special interest and/or expertise:

W-9 Form(Required)

If you don't have a W-9 Form available, you can download a blank form here: W-9 Form

Accepted file types: jpg, png, pdf, Max. file size: 15 MB.

Insurance Attachment

Current insurance certificate naming "Public Utility District No. 1 of Jefferson County" as additionally insured

Accepted file types: jpg, png, pdf, Max. file size: 15 MB.

Identify three (3) clients who will serve as references:

The applicant is hereby notified that all Washington State laws regarding prevailing wages and non-discrimination are applicable to ALL service provider contract activities.

All work is subject to Washington State Prevailing Wage.

I CERTIFY THAT INFORMATION SUPPLIED HEREIN (INCLUDING ALL PAGES ATTACHED) IS CORRECT.

Signature(Required)

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Email

This field is for validation purposes and should be left unchanged.