CFSC Fire Safe Vendor List Application "*" indicates required fields Step 1 of 5 20% 1. Vendor InformationBusiness Name* Sales Contact*This should be your sales representative and will be added to your listing if approved. First Last Contact Title* Contact Phone*Contact Email* Enter Email Confirm Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Website* Social handles*Years in business Please upload your logo here*Allowed file types: .jpg, .jpeg, .png, .epsAccepted file types: jpg, jpeg, png, eps, Max. file size: 2 MB. 2. Vendor Type and Area of ExpertiseType of Vendor* Fire Resistant Building & Materials Vegetation Management Services Emergency Response Equipment Fire Detection Software, Equipment, and Services Environmental Consultants Please include a 30-word or less list of services and/or products offered below.*Please be as detailed as possible so that potential clients know what you offer. If you are approved, this statement will go in your listing.Please include a 50-word or less statement that highlights what your business offers.*This is your promotional statement that can include more information on your business such as product/service results and/or guarantees, or other information that distinguishes you. If you are approved, this statement will go in your listing.What geographical area do you serve?*Select all that applyStatewideAlameda CountyAlpine CountyAmador CountyButte CountyCalaveras CountyColusa CountyContra Costa CountyDel Norte CountyEl Dorado CountyFresno CountyGlenn CountyHumboldt CountyImperial CountyInyo CountyKern CountyKings CountyLake CountyLassen CountyLos Angeles CountyMadera CountyMarin CountyMariposa CountyMendocino CountyMerced CountyModoc CountyMono CountyMonterey CountyNapa CountyNevada CountyOrange CountyPlacer CountyPlumas CountyRiverside CountySacramento CountySan Benito CountySan Bernardino CountySan Diego CountySan Francisco CountySan Joaquin CountySan Luis Obispo CountySan Mateo CountySanta Barbara CountySanta Clara CountySanta Cruz CountyShasta CountySierra CountySiskiyou CountySolano CountySonoma CountyStanislaus CountySutter CountyTehama CountyTrinity CountyTulare CountyTuolumne CountyVentura CountyYolo CountyYuba CountyPlease check all that apply Micro Business (10 employees or fewer) Minority Owned Buisness Veteran Owned Business Women Owned Business Select AllWho is your primary market right now?* Are you looking to get into other markets? If so, which ones? Do you have experience doing work with Fire Safe Councils and/or grant funded projects?* Yes No 3. Compliance and CertificationProof of Liability Insurance with California Fire Safe Council as an additional insured*Please upload your certificate of insurance with California Fire Safe Council added as an additional insured. If you carrier requires it, our address is 3237 Peacekeeper Way, Suite 201, McClellan, CA 95652Accepted file types: pdf, Max. file size: 2 MB.Proof of Workers' Compensation*Please upload your current certificate of Workers Compensation Insurance. If it is included with your certificate of insurance above, please upload it again.Accepted file types: pdf, Max. file size: 2 MB.Business License*Please upload your current business license.Accepted file types: pdf, Max. file size: 2 MB.Has your organization been suspended or debarred from receiving federal funds or contracts?* Yes No What is your Unique Entity Identification (UEI) number, if you have one? If you haven't already, please fill out AD-1048 and upload.Download AD-1048Accepted file types: pdf, Max. file size: 2 MB.Background CheckPlease provide all CSuite employees' names, title, DOB, city and state of residence, and email. This information and the results of the background check are confidential and will not be distributed to any other parties.CSuite Employee(s)*Name/TitleDOBHome City/StateEmail Add RemoveEnvironmental Responsibility and CertificationsPlease provide your environmental responsibility statement, if you have one, and mention any environmental certifications you have. Please also mention any additional certifications have (such as IBHS for home materials).ReferencesPlease provide up to three references for clients or partners who can vouch for your performance. Recommendations from government agencies and Resource Conservation Districts are helpful. Feel free to add notes about specific jobs, services, and/or products you provide.Reference*Name/Org(s)EmailPhoneNotes Add RemoveAlignment with CFSCPlease provide a statement of alignment with CFSC's mission. (This will not be included in your listing.) 4. Additional InformationPlease attach any additional information that supports your application.Accepted file types: pdf, txt, rtf, Max. file size: 2 MB. 5. Declaration and SignatureI, the undersigned, declare that the information provided in this application is true and accurate to the best of my knowledge. I understand that the submission of false or misleading information may result in the denial of my application for inclusion on the CFSC Vendors List.Vendor Representative's Full Name Date MM slash DD slash YYYY Δ
