Please fill out the following for Vendor Application. All fields are required.

Name of Company*


Mailing Address*


Physical Address*


List Type of Equipment, Supplies, Services and/or Materials you supply and the per unit cost/price to the City.

Contact Information

Bus. Phone*


Cell Phone*


FAX*


E-Mail*


Contact Person

Name*


Official Capacity*


Cell Phone*
State Tax ID #*


Fed Tax ID #*


Social Security #*
How long in business*


Contractor's License #*


Resident of Dasher?*
List of References*
List of Liability Insurance Carrier*
The City of Dasher reserves the right to select vendors based on cost, availability, and job performance. A listing of vendors for routine work to be done will be either bid out or a vendor will be selected randomly from an approved list of vendors who have completed this application. I certify that the information supplied herein (including attached pages detailing costs and prices) is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principal or officer, so far as is known, is now barred or otherwise declared in eligible by any public agency; I further certify that I (we), or any of my immediate family members, do not hold any official position with the City of Dasher as an elected official or paid employees.

Name and Date*





Information on this web site is deemed reliable but not guaranteed to be facts.