Return Completed Registration Form To

PacifiCorp

Vendor Registration Form

Return Completed Registration Form To:

PacifiCorp Procurement
Attention: Vendor Administration Coordinator
825 NE Multnomah Street, Suite 1800
Portland, Oregon 97232
Email: / Please Note:
1.  Registration forms without a signature will not be processed
2.  Incomplete registration forms will not be processed
3.  Provide signed copy of W-8 or W-9 Form
4.  A company work history is required

Please complete this form in detail using additional sheets as necessary. Catalogs/Brochures may be submitted as supplemental information.

Complete all sections, if a section does not pertain to your business, use N/A

SECTION 1:

Legal Business Name:
(MUST MATCH FEDERAL TAX IDENTIFICATION NUMBER)
Contact Name/Title:
Contact E-Mail Address:
Business Address:
STREET ADDRESS CITY STATE COUNTRY ZIP CODE
Mailing Address:
(IF DIFFERENT THAN ABOVE) / ADDRESS CITY STATE COUNTRY ZIP CODE
Phone/FAX Numbers: / () / ()
AREA CODE PHONE NUMBER AREA CODE FAX NUMBER
Internet URL:

Federal Tax Identification Number:

Please provide a signed copy of your W-8 or W-9, whichever form is applicable (Request for Taxpayer Identification Number and Certification form)

Are there any current or previous employees of PacifiCorp that are employees, officers, or principle stockholders in your company? Yes No

If yes, please list their names and positions within your company:

Are you an affiliate of Berkshire Hathaway or Berkshire Hathaway Energy Company? Yes No

If yes, please explain:

Are you a member of ISNetworld? (If a contract is awarded, your company may need to join ISNetworld, but it is not required as part of the registration process. You will be notified at a later point). Yes No

SECTION 2:

Company Structure and Financial Structure

Sole Proprietor / Partnership / Corporation / Affiliate / LLC
Joint Venture / Subsidiary / Non-Profit / Division of
Year Established: / Number of Employees: / State of Incorporation:
Dunn & Bradstreet Number: / Stock Symbol:
Dunn & Bradstreet Rating:
Parent Company Name and Incorporated Address:

FINANCIAL DATA

Please indicate your gross annual sales for the last three years. The most recent year is mandatory.

$ / Year
$ / Year
$ / Year

BUSINESS CLASSIFICATION

Are you a certified diversity enterprise? YES NO

*If Yes, please indicate which diversity classifications apply:

Gender / Race/Ethnicity (If more than one applies, please mark multiple entries) / Service Disabled Veteran /
LGBT
Female / American Indian/Alaskan Native / Yes / Yes
Male / Asian / No / No
Other, please specify below / Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
*If Yes, which agency or organization issued you the certification?

Please attach your certification.

BUSINESS INFORMATION

Have you performed work for, or supplied material to PacifiCorp, its parent company Berkshire Hathaway Energy Company or its affiliates? YES NO

If yes, provide list on an attached sheet and provide your PacifiCorp or Berkshire Hathaway Energy Company or affiliate vendor ID

number(s):

FOREIGN VENDORS

Are you a foreign vendor providing services in the United States? YES NO

*If yes, please provide your U.S. Tax ID number and a copy of your W-8 form.

SECTION 3:

Indicate geographical areas of business coverage, listing the primary branch location that will support the following states:

Oregon / Branch Location(s):
Washington / Branch Location(s):
California / Branch Location(s):
Idaho / Branch Location(s):
Utah / Branch Location(s):
Wyoming / Branch Location(s):

Work History

·  List the projects completed under the company’s present legal name within the last two (2) years for each of the types of work and/or services selected. Attach a separate listing for each type of service (boiler overhauls, balance of plant work, turbine valves, etc. (If required, attach additional information using the format shown below

Type of Work
Performed / Client Address
Contact Phone / Location
of Job / Contract
Value / Start/Complete
Date(s)

Safety

Does your company have a formal safety program? YES NO

SECTION 4:

Please check all categories that you provide:

Goods & Materials
Batteries / Fire Protection Equipment & Supplies / Office Equipment/Supplies/Furniture
Bearings / Gear Boxes / Oil Water Separators
Belts / Generators / Pipe Products Distributor
Bird Deterrent supplies / Hardware, Miscellaneous / Pipe, Valves & Fittings, Plastic/Steel
Building Supplies / Hardware, Pole Line / Plumbing Heaters & Supplies
Cable & Conductor / Hose & Hose Fittings / Poles, Concrete/Fiberglass/Steel/Wood
Capacitors / HVAC Equipment and Supplies / Pumps
Chemicals, Water Treatment / Ice Machines / Rectifiers
Circuit Breakers / Industrial Supplies / Relay Boards
Compressors / Instruments / Roofing/Siding/Gutter Supplies
Condensers / Insulators / Safety, Protective Equipment/Clothing
Construction Products / Janitorial Supplies / Scaffolding
Control Cabinets / Lifting & Rigging Equipment / Signage
Control instrumentation / Lighting/Fixtures & Supplies / Steel Structures
Cross Arms, Steel/Wood / Locks / Switches/Switchgear
Distribution Structures / Maintenance, Repair and Operations Supplies / Transformers, Power & Distribution
Doors / Manholes / Turbines, Gas/Hydro/Steam/Wind
Electrical Supplies / Material Handling Equipment & Supplies / Uninterruptable Power Supply
Fencing Materials / Metal Buildings / Welding Gases & Supplies
Filters, Air, Water & Oil / Meters / Windows
Fire Protection Equipment & Supplies / Motors / Other ______
Information Technology
Applications / Hardware & Infrastructure / Telecom
Consulting / Office Equipment / Other ______
Transportation
Forklifts / Third Party Logistics Services / Vehicle, Parts
Freight& Trucking Services / Tires / Vehicle, Rentals
Fuel / Vehicle, Filters / Vehicles, Light/Medium Duty/Utility
Oil & Lubricants / Vehicle Repairs / Other ______
General Services
Asphalt/Paving/Gravel Services / Insulation Services / Security Services
Caterings/Food Services / Janitorial Services / Surveying & Mapping
Circuit Breaker Maintenance / Machine Shop Services / Tank Cleaning and Repair Services
Crane Services / Pest Control Services / Traffic Control Services
Equipment Rental Services / Plumbing Services / Vegetation Management Services
Fabrication Services / Pressure Washing Services / Water Craft Repairs
Fencing Installation & Repair / Protective Coating Services / Water Treatment Services
Hazmat Remediation / Pump Repair Services / Weed Abatement Services
Hydro blasting Services / Road Maintenance Services / Welding Services
Inspection Services / Other ______
Professional Services
Advertising Services / Environmental Consultant Services / Other Professional Services
Architectural Services / Financial Services / Photographic Services
Audio Visual Services / Geotechnical Consulting Services / Project Management Services
Civil / Legal Services / Real Estate Services
Electrical / Lobbyist Services / Safety Consultant Services
Engineering Design & Drafting / Mechanical / Staff Augmentation Services
Facility Services
Building & Facility Services / HVAC Services / Paving Services
Building Repair Services / Interior Remodeling Services / Plumbing Services
Electrician Services / Janitorial Services / Roofing Services
Elevator Services / Landscaping Services / Snow Removal Services
Fencing Installation & Repair / Overhead Door Services / Other ______
Floor Covering Services / Painting Services
Power Generation - Specialty Goods and Services
Ash Handling Systems & Supplies / Conveyor Belts & Suppliers / Mining, Explosives & deslagging
Ash Ponds / Cooling Towers & Supplies / Heavy Equipment
Backflow Preventer Services / Emission Control Systems & Supplies / Oil Water Separator Services
Boiler Chemicals / Gate Services / Power Plant Overhaul Services
Boiler Tubing / Generator Services / Precipitator and/or scrubbers
Coal Handling Equipment & Supplies / Marine Diving Services / Retention Ponds/Drainage
Condensate Systems & Supplies / Marine Dredging Services / Wind Operations &Maintenance Services
Construction Services, Balance of Plant / Marine, Booms and Deployment / Other ______
Transmission & Distribution Specialty Services
Helicopter Services / Pole Test and Treat Services / Substation Construction Services
Line Repair Services / Right of Way Services / Vegetation Management Services
Locating Services / Street Light Maintenance Services / Other ______

Please summarize below how your organization can provide value to PacifiCorp.

I ACKNOWLEDGE AND REPRESENT THAT THE INFORMATION FURNISHED IS COMPLETE AND FACTUAL
mm/dd/yy
SIGNATURE / TITLE / DATE
Printed name / Printed Title

NOTE: The box above must be filled out and signed (or electronically signed) and dated or

the vendor registration form will be deemed invalid.

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Revision 06-16-2015