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1692799v1 STANDARD AGREEMENT, PAGE 2 OF 2 BIDDER INFORMATION 1. Legal Name of Bidder: ______________________________________________________________________________ 2. Bidder’s Street Address: ______________________________________________________________________________ 3. Mailing Address: ______________________________________________________________________________ 4. Business Telephone: _______________ Fax Number: ________________ 5. Type of Supplier: □ Sole Proprietor □ Partnership □ Corporation □ LLC If Corporation, indicate State where incorporated: ____________________ 6. Business License Number issued by the City where the Supplier’s principal place of business is located. Number: ____________________ Issuing City: _____________________ 7. Supplier Federal Tax Identification Number: ____________________________ 8. Emergency Contact: Name: ____________________________________ Phone Number: ______________________________ 9. Order Contact: Name: _______________________________________ Address: _______________________________________ Phone Number: ___________ Fax Number: ____________ Email: __________________________________________ 10. References: Company/Agency Name Contact Name Phone Number 1)_________________________ ___________________ _____________ 2) _________________________ ___________________ _____________ 3) _________________________ ___________________ ______________ 11. Chemical Manufacturer’s name and address (if different from Bidder): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 50