Washington Counties Risk Pool

WASHINGTON COUNTIES RISK POOL

2558 RW JOHNSON RD SW, SUITE 106

TUMWATER, WA 98512

Vendor List Enrollment Application

Company Name: ______

Contact Name: ______

Mailing Address: ______

City: ______State: ______Zip Code: ______

Email: ______

Telephone Number: ______Fax Number: ______

Business License Number: ______

Federal Tax ID Number: ______

Check box(es) that describes the types of materials, supplies and equipment your business may provide:

Office Supplies ______Cleaning Supplies ______

Computer Supplies______Computer Equipment ______

Janitorial Services ______Building Maintenance/Supplies ______

Automotive Repairs & Service____ Automotive Sales ______

Document Printing/Publishing ______

Other: ______Describe: ______

You are notified that the Washington Counties Risk Pool must comply with the prevailing wage laws of the State of Washington (RCW 39.12) and requires all contractors it does business with to comply as well.

______

Printed Name & Title Signature Date