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Home My WebLink AboutCAG2017-0337 - Original - DSHS - Contractor Intake Application - 05/09/2017 Washington stafe 7 Department of Social Contractor Intake &Health Services Section One: Contractor Name/Business Organization (DSHS staff enter on ACD Intake Detail screen) 1. CONTRACTOR NAME DBA OR FACILITY NAME Kent Police Department 2. BUSINESS ORGANIZATION ❑ Individual or Sole Proprietor ❑ General Partnership ❑ Non-Profit Corporation (Attach a copy of 501(c) status) ❑ Limited Liability Partnership (LLP) ❑ For Profit Corporation ❑ Limited Liability Limited Partnership (LLLP) ❑ Faith Based (FBO) Non-Profit Corporation ❑ Limited Liability Company, filing as a Corporation ❑ Faith Based (FBO) Unincorporated ❑ Limited Liability Company, filing as a Partnership i ® Governmental Entity ❑ Limited Liability Company, filing as a Sole Proprietor ❑ Foreign Person or Entity If your business is NOT a sole proprietorship, attach a list of the partners, members, directors, officers, and board members. 3. TAXPAYER IDENTIFICATION NUMBER(TIN) Social Security Number Enter your TIN in the appropriate box. (Enter all 9 numbers, For individuals, this may be your Social Security Number OR NO DASHES) (SSN). Employer Identification 91-6001254 Number (Enter all 9numbers, o For other entities, it is your Employer Identification Number, NO DASHES) 4. DEFAULT REPORTED, FISCAL YEAR, UBI NUMBER, BUSINESS LICENSE,AND DUNS NUMBER I Have you had any contract with the state terminated for default? ❑ Yes ® No If yes, attach a list of terminated contracts with an explanation why each contract was terminated. Is your fiscal year end the same as the calendar year(January 1 through December 31)? ® Yes ❑ No If the answer is no, what is your fiscal year end date? What is your Washington State Uniform Business Identifier (UBI) Number? 173-000-002 (Enter all 9 numbers, NO DASHES) I Attach a copy of your current Washington State Master Business License. If you do not have a Washington State Master Business License, explain below why you are exempt from registering your business with the State of Washington. (See page 1 for information on exemptions.) What is your Dun and Bradstreet (DUNS) number? 020253613 (Enter all nine numbers, NO DASHES. Section Two: Contractor Primary Address (DSHS staff enter on ACD Intake Detail screen) CONTRACTOR PRIMARY ADDRESS(NUMBER,STREET,AND APARTMENT OR SUITE NUMBER) 220 4th Avenue South CITY, STATE,AND ZIP CODE Kent, WA 98032 EMAIL ADDRESS COUNTY WHERE PRIMARY ADDRESS IS(FOR OUT-OF-STATE CONTRACTORS) jswood@kentwa.gov King I - j PHONE NUMBER(INCLUDE AREA CODE) FAX NUMBER(INCLUDE AREA CODE) (253) 856-5856 (253) 856-6800 DSHS 27-043(REV.05/2015) Page 2 of 4 Section Three: Contractor Ownership Type (DSHS staff enter, as applicable, on ACD Intake Detail screen) In your opinion, do you consider your business to be one or If your business is Certified by Washington State's Office more of the following? If so, please check the boxes that of Minority and Women Owned Business Enterprises apply. (OMWBE)LLtp;Ilwww-omwbe.wa-gav, or Department of YES NO Veterans Affairs (DVA), enter the certification number. Disadvantaged Business Enterprise ❑ Woman Owned Business Enterprise ❑ Minority Owned Business Enterprise ❑ Veteran Owned Business Enterprise ❑ Community Based Organization ❑ ® - Microbusiness ❑ Minibusiness El Z Small Business ❑ Section Four: Contractor Primary Contact Person (DSHS staff enter on ACD Intake Detail screen) Primary contact person is a(n): ❑ Owner ❑ Officer or Board Member ❑ Partner ® Staff Member ❑ Elected Official ❑ Other(please identify) (DSHS staff enter as applicable on ACD) Is the primary contact person authorized to sign contracts? ® Yes ❑ No PRIMARY CONTACT NAME AND JOB TITLE PHONE NUMBER(INCLUDE AREA CODE) Ken Thomas, Chief of Police (253) 856-5800 FAX NUMBER(INCLUDE AREA CODE) PRIMARY CONTACT EMAIL ADDRESS (253) 856-6800 kthomas@kentwa.gov PAGER NUMBER(INCLUDE AREA CODE) CELLULAR PHONE NUMBER(INCLUDE AREA CODE) ( ) ( ) Section Five: Additional Information (DSHS staff enter on Intake Detail—Sub Information Summary screens) 1. ADDITIONAL CONTRACTOR ADDRESSES: IF YOU HAVE MORE THAN TWO ADDITIONAL ADDRESSES,YOU MAY ATTACH A LISTING OF ADDITIONAL ADDRESSES. ADDRESS ADDITIONAL ADDRESS(NUMBER, STREET,AND APARTMENT OR SUITE NUMBER) DESCRIPTION ❑ Billing address ❑ Facility address CITY,STATE,AND ZIP CODE ❑ Mailing address PHONE NUMBER(INCLUDE AREA CODE) COUNTY WHERE PRIMARY ADDRESS IS(FOR OUT-OF-STATE CONTRACTORS) FAX NUMBER(INCLUDE AREA CODE) EMAIL ADDRESS ( ) I ADDRESS ADDITIONAL ADDRESS(NUMBER, STREET,AND APARTMENT OR SUITE NUMBER) DESCRIPTION ❑ Billing address ❑ Facility address CITY, STATE,AND ZIP CODE ❑ Mailing address PHONE NUMBER(INCLUDE AREA CODE) COUNTY WHERE PRIMARY ADDRESS IS(FOR OUT-OF-STATE CONTRACTORS) ( ) FAX NUMBER(INCLUDE AREA CODE) EMAIL ADDRESS l ) i - ... . DSHS 27-043(REV.0512015) Page 3 of 4 2. ADDITIONAL STAFF: IF YOU HAVE MORE THAN TWO ADDITIONAL STAFF(LISTED BELOW),WHO ARE ALSO RELEVANT TO YOUR DSHS CONTRACTS, PLEASE PROVIDE INFORMATION ABOUT THOSE STAFF ON A SEPARATE PAGE. Additional staff person is a(n): ❑ Officer or Board Member ❑ Partner ® Staff Member ❑ Elected Official ❑ Other (please identify) (DSHS staff enter as applicable on ACD) Is the additional staff authorized to sign contracts? ❑ Yes ® No Is the additional staff a contact for DSHS Contracts? ® Yes ❑ No ADDITIONAL STAFF NAME PHONE NUMBER(INCLUDE AREA CODE) Sara Wood (253) 856-5856 FAX NUMBER(INCLUDE AREA CODE) ADDITIONAL STAFF EMAIL ADDRESS (253) 856-6800 swood@kentwa.gov PAGER NUMBER(INCLUDE AREA CODE) CELLULAR PHONE NUMBER(INCLUDE AREA CODE) ( ) ( ) Additional staff person is a(n): ❑ Officer or Board Member ❑ Partner ❑ Staff Member ❑ Elected Official ❑ Other(please identify) (DSHS staff enter as applicable on ACD) Is the additional staff authorized to sign contracts? ❑ Yes ❑ No Is the additional staff a contact for DSHS contracts? ❑ Yes ❑ No ADDITIONAL STAFF NAME PHONE NUMBER(INCLUDE AREA CODE) ( ) FAX NUMBER(INCLUDE AREA CODE) ADDITIONAL STAFF EMAIL ADDRESS ( 1 PAGER NUMBER(INCLUDE AREA CODE) CELLULAR PHONE NUMBER(INCLUDE AREA CODE) ( ) ( ) Section Six: Contractor Certification (DSHS staff enter on ACD Intake Detail as Intake Form Date) You must sign, date, and return this form. I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of the foregoing statements re true nd correct, and that I will notify DSHS of any changes in any statement. SIGNATURE DATE PRINTED NAME Ken Thomas _ 05/09/2017 TITLE �1q Chief of Police ATTACHED SUPPORT[ G DOCUMENTATION CHECKLIST ® Copy of your W-9- Request or Taxpayer Identification Number and Certification ❑ Copy of statement showing non-profit 501(c) status (if applicable) ❑ List of partners, members, directors, officers, and board members (not applicable to sole proprietors) ® Copy of your Washington State Master Business License or proof of exemption ❑ List of any contracts you have had with the state that have been terminated for default, including a brief explanation (if applicable) ® List of Additional Addresses (if applicable) ® List of Additional Staff (if applicable) ❑ COPY Of your Certificate of Insurance (if applicable) DSHS 27-043(REV. 05/2015) Page 4 of 4