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2. CITY DEPARTMENT
   ____________________________
4. City Department*
   -- Select One --BuildingCDBGCity ClerkEngineeringFinanceFireHuman ResourcesITMayor's OfficePlanning and ZoningPolicePublic RelationsPublic Works

   Please select which city department your request applies to.

6. COMPANY DETAILS:
   ____________________________
8. Company Type*
   -- Select One --Corporation / LLCSole ProprietorNon-Illinois Vendor

   Please select an option.
10. Company Name*
11. Company FEIN*
13. Sole Proprietor Name*
14. Services*
    State services to be provided to the city.
16. Non-Illinois Vendor Company Name*
18. DUNS Number
20. CONTACT INFORMATION:
    ____________________________
22. First Name
23. Last Name
25. E-Mail*
26. Phone Number*
27. Extension
29. Website
31. TAX REPORTING REQUIREMENTS:
    ____________________________
33. Type of Business*
    -- Select One --IndividualSole ProprietorSingle Member LLCC CorporationS CorporationPartnershipTrust / EstateLLCOther
34. Tax Reportable*
    -- Select One --YesNo
36. If answer "No" for Tax Reportable, please give reason for exemption
38. ATTACHMENTS: W-9*
    Please upload completed and signed W-9.
39. ATTACHMENT: Certificate of Good Standing*
    Please upload certificate of Good Standing.
41. ATTACHMENT: Assumed Business Name*
    Please upload Assumed Business Name Certificate
42. ATTACHMENT: Non-Illinois Vendor*
    Please upload your Non-Illinois Vendor company certificate for the state in which you are registered.
44. ATTACHMENT: Sole Proprietor Form*
    Please email wkpurchasing@waukeganil.gov to obtain form.
46. ATTACHMENTS: BEP, MBE, FBE, VBP
    Please upload, if applicable, a copy of your State of Illinois Central Management Services' Business Enterprise Program (BEP), or Minority Owned Business Enterprise (MBE), or Female Owned Business Enterprise (FBE), or Disabled-Person Owned Business Enterprise (PBE) or Veterans Business Program (VBP) Certificate. Any other certificate will not be accepted.
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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field