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VENDOR MAINTENANCE FORM <br />Print Form <br />Requesting Department:Engineering <br />Contact:Kyle Silveus <br />Phone:574-235-9083 <br />Remit To Address - (Send payments to this address) <br />Supplier Name: Bokon Masonry Inc. <br />Address 1: 56571 Pear Rd. <br />Address 2: <br />City, State, ZIP: South Bend, IN 46619 <br />Contact: Ryan Bokon <br />Indicate below if P.O. Address is different. <br />Address/P.O. Box: N/A <br />Date:2018-10-16 <br />Action: (: Add C Inactivate <br />E-mail: ryan.bokonmasonryinc@yahoo.com <br />Phone: 574-993-6771 <br />FAX: 574-404-6105 <br />Tax ID# / SS#: 46-0639161 <br />W-9 Form is required and must be attached <br />City, State, ZIP: N/A <br />Vendor Qualifications: <br />Type of Items Supplied: Masonry Construction and Repairs and Restoration <br /># of years in business: 7 # of employees: 8 <br />Sales - $'s Annual: $800,000.00 DUNNS #: <br />Major customers: South Bend Heritage Foundation <br />Is the business certified as a Disadvantaged Business enterprise? ('Yes (*-No <br />Type: (' WBE ( MBE Other: If MBE, please indicate ethnic origin: <br />Name & address of agency that provided your MBE or WBE certification: <br />Date Certified. <br />Date Certification Expires: <br />Note: Vendor record must be created prior to a commitment for supplies or services. <br />Commen <br />Purchasing Approval: <br />Instructions: <br />1. Complete Form <br />2. Print to PDF CREATOR (which will create a file) <br />3. Attach the file to an E-MAIL addressed to: GKING@SOUTHBENDIN.GOV <br />Rev.082412a <br />