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Question	Answer
Form Name	Vendex Nyc
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	nyc dept of education health screening questionnaire pdf, new york city questionnaire, new york city vendex, vendex nyc

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Bill de Blasio

Mayor

Lisette Camilo

City Chief Procurement

Officer and Director of

Contract Services

253 Broadway, 9th Floor

New York, NY 10007

212 788 0010 tel

212 788 0049 fax

September 25, 2014

Please note that effective, September 25, 2014, the VENDEX questionnaires are now fillable. YOU WILL STILL NEED TO COMPLETE, PRINT AND SUBMIT THE PAPER COPIES. These include the:

•Vendor Questionnaire

•Principal Questionnaire

•Certification of No Change

Please be advised that certain fields require certain types of entry, e.g.:

•Date fields require entries to match: MM/DD/YYYY

•Telephone/Fax fields require entries to match: XXX-XXX-XXXX or (XXX) XXX-XXXX

•EIN/TIN/SSN fields require 9 digits and no dashes

•SSN only fields require entries to match XXX-XX-XXXX

Please also note that not all the fields will match the underlying formatting due to the limitations of the form, but ALL information will be able to be inputted. If you have any questions or concerns with the form, please email us at VENDEXFEEDBACK@cityhall.nyc.gov and we will get back to you as soon as possible.

PLEASE NOTE THAT ALTHOUGH THE FORMS ARE FILLABLE, YOU WILL STILL NEED TO

COMPLETE, PRINT AND SUBMIT THE PAPER COPIES.

Thank you for your kind consideration.

Printed on paper containing 30% post-consumer material.

Principal Questionnair	Fillable 9/25/14		Revised 9/25/14
	Fillable 9/25/14
Page 1 of 7	Principal’s SSN	-		-

PRINCIPAL QUESTIONNAIRE

The Vendor Information Exchange System (VENDEX) includes two questionnaires – the vendor questionnaire and the principal questionnaire. These have been developed to collect information from vendors who wish to do business with New York City, to ensure that New York City obeys the mandate in its charter to do business only with responsible vendors.

Questionnaires may be obtained in paper format from the VENDEX Unit (212-341-0933) or downloaded from the NYC website at http://www.nyc.gov/vendex.

Questionnaires must be completed in paper format. All questions must be answered. Aresponse of “Not Applicable (N/A)”, or the equivalent, is not acceptable. Answers must be typewritten or printed in ink. If more space is needed to respond, photocopy the corresponding section’s page, check the box that additional information is attached, and attach the photocopied page to the questionnaire.

The publication “Vendor’s Guide to VENDEX” provides assistance and explanation for the questionnaires, including definitions of terms or phrases written in bold face throughout the questionnaires. If you have not obtained a copy of this publication, please download a copy from the New York City web site, or contact the VENDEX Unit at 212-341-0933. All forms must be sent to MOCS: 253 Broadway, 9th Floor; New York, New York 10007. If you have questions, contact the VENDEX Unit at 212-341-0933.

ANSWER THIS QUESTIONNAIRE CAREFULLY AND COMPLETELY. FAILURE TO SUBMIT A FULLY COMPLETED QUESTIONNAIRE MAY RESULT IN THE REJECTION OF THE VENDEX SUBMISSION. MAKING ANY UNAUTHORIZED CHANGE OR ALTERATION TO THE QUESTIONNAIRE WILL RENDER IT VOID.

Name of submitting vendor

Submitting vendor’s EIN/SSN/TIN

Type of submission: (Check one)

1.Full questionnaire

2.Changed questionnaire

If checked, provide submission date of last full questionnaire:

Name of person completing this principal questionnaire

Employer/Title

Telephone Number (

)

Fax Number (

)

Email address

The disclosure of the social security number is mandatory under the right granted New York City by the Tax Reform Act of 1976 and will be used for the purpose of tax administration. The number may also be used for general identification purposes. If you do not consent to such additional use for general identification purposes, please check here

Provide a detailed response for all questions answered with information and/or “YES” in the question’s corresponding section starting on page four of this questionnaire.

Principal Questionnaire				Revised 9/25/14
Page 2 of 7	Principal’s SSN		-		-

1. Principal owner or officer’s name

SSN

Date of birth

Home address

Street/P.O. Box/Apt Number

Floor #/Suite #

City/State/Zip Code

Primary place of business address

Street/P.O. Box/Apt Number

Floor #/Suite #

City/State/Zip Code

Business telephone (

)

Business fax number (

)

Business email address

2. State all positions (with dates) held with submitting vendor during the past five (5) years

Title of position held:

Dates held

From

Check if more than three (3) positions were held, and attach list of titles and dates held

Yes

Do you hold a ten (10) percent or greater ownership interest in the

submitting vendor?

Yes

Are there any outstanding loans, guarantees or any other form of security

or lease or any other type of contribution made in whole or in part between

you and the submitting vendor?

Yes

Within the past three (3) years, have you been a principal owner or officer

of any entity other than the submitting vendor?

Yes

Has New York City awarded any contracts to an entity listed in response

to Question 5 while you were a principal owner or officer?

Provide a detailed response for all questions answered with information and/or “YES” in the question’s corresponding section starting on page four of this questionnaire.

Principal Questionnaire		Revised 9/25/14
Page 3 of 7	Principal’s SSN		-		-

7.At any time during the past five (5) years, have you, and/or any entity in which you have been a principal owner or officer, been subject to any of the following actions, whether pending or completed:

a..No Yes debarred from bidding on any government contract?

b.No Yes found non-responsible on any government contract?

c.	No	Yes declared in default and/or terminated for cause on any contract, and/or had
		any contract canceled for cause?
		any contract canceled for cause?

No Yes determined to be ineligible to bid or propose on any contract?

No Yes suspended from bidding on any government contract?

No		Yes received an overall unsatisfactory performance rating from any government
		agency on any contract or agreement?
		agency on any contract or agreement?

8. Do you presently serve, or have you within the past five (5) years served, as:

a.	No	Yes	an elected or appointed official or officer?

b.	No	Yes	a full or part-time employee in a New York City agency or as a consultant to
b.	No	Yes
			any New York City agency?
			any New York City agency?

c.	No	Yes	an officer of any political party organization in New York City, whether paid or
			unpaid?
			unpaid?

d.	No	Yes	as a consultant or advisor to a New York City agency that is or was involved
			in the solicitation, negotiation, operation and/or administration of contracts on

			which the submitting vendor will work during this three year VENDEX cycle?

9. During the past five (5) years, have you failed to:

a.No Yes file any applicable federal, state or New York City tax returns?

b.	No	Yes pay any applicable federal, state or New York City taxes or other assessed
		New York City charges, including but not limited to water and sewer charges?

Provide a detailed response for all questions answered with information and/or “YES” in the question’s corresponding section starting on page four of this questionnaire.

Principal Questionnaire				Revised 9/25/14
Page 4 of 7	Principal’s SSN		-		-

Provide details to questions answered “yes” in the corresponding section below.

Corresponds to Question 3.

Total percentage of stock owned:

Purchase date:

(if sole proprietorship,

enter 100%)

Corresponds to Question 4. (check all that apply)

Loan amount

Lease amount

Guarantee amount

Other

(Name)

Security amount

Other

(Name)

Corresponds to Question 5.

Name of entity of which you are/were a principal owner or officer

Address

EIN/TIN

Telephone number (

)

Your title

Associated from

Still serving

Check if attaching additional information

Corresponds to Question 6.

Name of entity that received the contract

EIN/TIN

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one - three. If you need more space to respond, photocopy the corresponding section’s page, check the box that additional information is attached, and attach the photocopied page to this Questionnaire.

Principal Questionnaire				Revised 9/25/14
Page 5 of 7	Principal’s SSN		-		-

Corresponds to Question 7. (Use this box for only one action. For each additional action, photocopy this page, complete the information and attach to this questionnaire.)

The following refers to section:

Action applies to:

You (as principal owner or officer)

Entity. If checked, name

Entity’s EIN/TIN

Your title (as principal owner or officer) (while action was underway)

Action is:

Pending

Completed

Date of action

From

Still ongoing

Name of agency initiating action

Contract number

Reason for action

Check if attaching additional information

Corresponds to Question 8. (check all that apply)

8a.

elected official

elected officer

appointed official

Name of agency where you serve(d)

Date started

Date completed

Still Serving

Check if attaching additional information

8b.

Full time employee

Part time employee

Consultant to NYC agency

Name of agency where you work(ed)

Date started

Date completed

Still Serving

Check if attaching additional information

8c.

paid officer

unpaid officer

Name of political party or organization

Date started

Date completed

Still Serving

Check if attaching additional information

8d.

Individual serves/served New York City agency as

consultant

advisor

Employee/advisor’s name

SSN

Date of Birth

Name of NYC agency

Check if attaching additional information

Principal Questionnaire

Revised 9/25/14

Page 6 of 7

Principal’s SSN

Corresponds to Question 9.

9a.

You failed to file

Federal taxes

State taxes

N.Y. City taxes

Other

If “State” is checked, and other than N.Y., name State

If “Other“ is checked, specify

Taxes were not filed for tax years:

Check if attaching additional information

9b.

You failed to pay:

Federal taxes

State taxes

N.Y. City taxes

Other NYC charge

If “State” is checked, and other than N.Y., name State

If “Other NYC charge(s)” is checked, specify

Taxes were not paid for tax years:

Check if attaching additional information

Principal Questionnaire				Revised 9/25/14
Page 7 of 7	Principal’s SSN		-		-

CERTIFICATION

THE PRINCIPAL QUESTIONNAIRE MUST BE CERTIFIED BYTHE PRINCIPAL COMPLETINGTHE QUESTIONNAIRE. A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS QUESTIONNAIRE MAY RESULT IN RENDERING THE SUBMITTING VENDOR NON-RESPONSIBLE WITH RESPECT TO THE VENDEX SUBMISSION AND, IN ADDITION, MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRIMINAL CHARGES.

I,		serving as		for	,

	Name		Title		Submitting Vendor’s Name

being duly sworn, certify that:

•I have not altered the substance of this questionnaire in any manner;

•I have read and understand all of the items contained in the foregoing 6 pages of this

questionnaire and the following

pages of attachments;

•I supplied full and complete responses to each item therein to the best of my knowledge, information and belief;

•I understand that New York City will rely on the information supplied in this questionnaire as an inducement to enter into a contract with the submitting vendor;

•I understand that at the time of execution of any contract with New York City, the submitting vendor will be required to certify that the information I have supplied remains accurate, and I further understand that I may provide to the VENDEX unit, in writing, any change(s) in the information provided in this questionnaire at the time of any change in the circumstances;

•I have read the vendor questionnaire submitted by the submitting vendor, and the answers thereto, and that, to the best of my knowledge, information and belief, those answers are full, complete and accurate.

Sworn to before me this		day of		, 20	;

Notary Public

Print name

Signature

/ /

Date

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