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PTC Form # 79-07
PENNSYLVANIA TURNPIKE COMMISSION
Bidder’s Mailing List Application

ORGANIZATIONAL DATA
Company Name: PTC Vendor # (What's This?):
Company Name 2:    
ADDRESS TO WHICH BIDS AND PURCHASE ORDERS ARE TO BE MAILED
Street Address
Street Address
City    State      Zip  
Phone    Fax   
Primary Company Email Address
(Please provide a general email address such as "sales@company.com" if possible)
REMIT TO ADDRESS (IF DIFFERENT THAN ABOVE)
Corporate Name (if different)
Street Address
Street Address
City State Zip
TAX NUMBERS
Federal Taxpayer # (What's This?)
 SSN (Numbers Only. No Dashes) (If individual/Sole Proprietor)
 Employer ID Number (Numbers Only. No Dashes) (If Corporation or Partnership)
PA State Tax License # (Numbers Only. No Dashes)
CONTACT PERSONS
 
Full Name Function
Phone Fax
Mobile Email
 
Full Name Function
Phone Fax
Mobile Email
 
Full Name Function
Phone Fax
Mobile Email
 
WOMEN/MINORITY/DISADVANTAGED BUSINESS STATUS
NOTE: SECTION 4107.2 OF THE PENNSYLVANIA CRIMES CODE MAKES IT A FELONY OF THE THIRD DEGREE FOR A PERSON TO OBTAIN OR RETAIN CERTIFICATION FRAUDULENTLY, OR TO MAKE A WILLFUL FALSE STATEMENT (ORAL OR WRITTEN) FOR THE PURPOSE OF INFLUENCING A CERTIFICATION DECISION.
Application Status Certification Date
(mm/dd/yyyy)
Please forward evidence attesting to certification to:
Pennsylvania Turnpike Commission
Contracts Administration Department
P O Box 67676
Harrisburg PA 17106
DEFINITION: Women/Minority/Disadvantaged Business Enterprise is a small business concern: is at least 51% owned by one or more socially and economically disadvantaged individuals, or, in the case of any corporation at least 51% of the stock of which is owned by one or more socially and economically disadvantaged individuals; AND whose management and daily business operations are controlled by one or more of the socially and economically disadvantaged individuals who own it.

Socially and Economically Disadvantaged Individuals are citizens of the United States (or lawfully permanent residents) who are Black Americans, Hispanic Americans, Native Americans, Asian-Pacific Americans, Asian-Indian Americans, or women or other individuals found to be disadvantaged by the Small Business Administration pursuant to Section 8 (a) of the Small Business Act, as amended, or other public body.
SURVEY QUESTIONS
What is your preferred method of receiving Purchase Orders?
If PTC offered any of the following options, would your company be willing to:
Submit bids via e-mail?  Yes   No 
Participate in Live Auctions via the Internet?  Yes   No 
Submit invoices electronically?  Yes   No 
  


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