Purchasing Office
127 Center Street, South
Vienna, VA 22180
Date of Submission: __/__/____
Email: csmoot@viennava.gov
Update of current application
Phone: 703-255-5755
Fax: 703-255-5729
BIDDERS APPLICATION FORM
I certify that all information supplied herein is correct to the best of my knowledge and that the applicant is not debarred to supply materials or services to any
public agency. I also understand that it is my responsibility to update this information in the event that any changes occur, to remain on the Town’s bidder’s list.
________________________________________ ______________________________________ __________________________________
Authorized Signature of Applicant Title Date
TOWN OF VIENNA
Persons to contact regarding bids, contracts, or purchase orders
Name
Title
Telephone No.
Fax No.
1. ___________________________________________________________________________________________________
2.___________________________________________________________________________________________________
Firm Name:
FIN or SSN
(Applicant)
______________________________________________________________________________________________________
Street
______________________________________________________________________________________________________
City/State/Zip:
______________________________________________________________________________________________________
Email: ___________________________________________ Local jurisdictions you’ve been awarded a