PacifiCorp Vendor Registration Form
Return Completed Registration Form To:
Please Note: PacifiCorp Procurement 1. Registration forms without a signature will not be Attention: Vendor Administration Coordinator processed 825 NE Multnomah Street, Suite 1800 2. Incomplete registration forms will not be processed Portland, Oregon 97232 3. Provide signed copy of W-8 or W-9 Form
4. A company work history is required Email: [email protected]
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: ( ) ( ) AREA CODE PHONE NUMBER AREA CODE FAX NUMBER Internet URL:
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 ISNetworld? (If a contract is awarded, your company may need to join ISNetworld, 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: Stock Symbol: Dunn & Bradstreet Rating:
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:
Race/Ethnicity (If more than one applies, please Service Disabled Gender mark multiple entries) 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 Client Address Location Contract Start/Complete Performed Contact Phone of Job Value 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:
Goods & Materials Batteries Fire Protection Equipment & Supplies Office Equipment/Supplies/Furniture
Bearings Gear Boxes Oil Water Separators
Belts Generators Pipe Products Distributor
Bird Deterrent supplies Hardware, Miscellaneous Pipe, Valves & Fittings, Plastic/Steel
Building Supplies Hardware, Pole Line Plumbing Heaters & Supplies
Cable & Conductor Hose & Hose Fittings Poles, Concrete/Fiberglass/Steel/Wood
Capacitors HVAC Equipment and Supplies Pumps
Chemicals, Water Treatment Ice Machines Rectifiers
Circuit Breakers Industrial Supplies Relay Boards
Compressors Instruments Roofing/Siding/Gutter Supplies
Condensers Insulators Safety, Protective Equipment/Clothing
Construction Products Janitorial Supplies Scaffolding
Control Cabinets Lifting & Rigging Equipment Signage
Control instrumentation Lighting/Fixtures & Supplies Steel Structures
Cross Arms, Steel/Wood Locks Switches/Switchgear
Distribution Structures Maintenance, Repair and Operations Supplies Transformers, Power & Distribution
Doors Manholes Turbines, Gas/Hydro/Steam/Wind
Electrical Supplies Material Handling Equipment & Supplies Uninterruptable Power Supply
Fencing Materials Metal Buildings Welding Gases & Supplies
Filters, Air, Water & Oil Meters Windows
Fire Protection Equipment & Supplies Motors Other ______
Information Technology Applications Hardware & Infrastructure Telecom
Consulting Office Equipment Other ______
Transportation
Forklifts Third Party Logistics Services Vehicle, Parts
Freight& Trucking Services Tires Vehicle, Rentals
Fuel Vehicle, Filters Vehicles, Light/Medium Duty/Utility
Oil & Lubricants Vehicle Repairs Other ______
General Services Asphalt/Paving/Gravel Services Insulation Services Security Services
Caterings/Food Services Janitorial Services Surveying & Mapping
Circuit Breaker Maintenance Machine Shop Services Tank Cleaning and Repair Services
Crane Services Pest Control Services Traffic Control Services
Equipment Rental Services Plumbing Services Vegetation Management Services
Fabrication Services Pressure Washing Services Water Craft Repairs
Fencing Installation & Repair Protective Coating Services Water Treatment Services
Hazmat Remediation Pump Repair Services Weed Abatement Services
Hydro blasting Services Road Maintenance Services Welding Services
Inspection Services Other ______
Professional Services Advertising Services Environmental Consultant Services Other Professional Services
Architectural Services Financial Services Photographic Services
Audio Visual Services Geotechnical Consulting Services Project Management Services
Civil Legal Services Real Estate Services
Electrical Lobbyist Services Safety Consultant Services
Engineering Design & Drafting Mechanical Staff Augmentation Services
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Facility Services Building & Facility Services HVAC Services Paving Services
Building Repair Services Interior Remodeling Services Plumbing Services
Electrician Services Janitorial Services Roofing Services
Elevator Services Landscaping Services Snow Removal Services
Fencing Installation & Repair Overhead Door Services Other ______
Floor Covering Services Painting Services
Power Generation - Specialty Goods and Services Ash Handling Systems & Supplies Conveyor Belts & Suppliers Mining, Explosives & deslagging
Ash Ponds Cooling Towers & Supplies Heavy Equipment
Backflow Preventer Services Emission Control Systems & Supplies Oil Water Separator Services
Boiler Chemicals Gate Services Power Plant Overhaul Services
Boiler Tubing Generator Services Precipitator and/or scrubbers
Coal Handling Equipment & Supplies Marine Diving Services Retention Ponds/Drainage
Condensate Systems & Supplies Marine Dredging Services Wind Operations &Maintenance Services
Construction Services, Balance of Plant Marine, Booms and Deployment Other ______
Transmission & Distribution Specialty Services Helicopter Services Pole Test and Treat Services Substation Construction Services
Line Repair Services Right of Way Services Vegetation Management Services
Locating Services Street Light Maintenance 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
mm/dd/yy SIGNATURE TITLE DATE
Printed name Printed Title
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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