Service Provider Application Form Please read and acknowledge Tegrete’s Client Confidentiality Agreement. Contact Information Please include primary contact informationLegal Business Name*(as stated on tax documents)DBA NameBusiness Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Name* First Last Job TitleBusiness Phone*FaxCell PhoneEmergency PhoneEmail* Payment Information Where should Tegrete send payments for services? Fields are populated based on your entries from the previous page. Please make changes as necessary, for payment info.Company Name for Payments*Contact Name for Payments* First Last Email Address for Payments* Phone for Payments*Fax for PaymentsPayment Address* Same as previously entered business address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company Information Please tell us more about your companyType of Firm*This information must match your W9 formIndividual/Sole ProprietorCorporation/Sub Chapter S CorpPartnershipLLC-CLLC-PLLC-STax ID (EIN)*Years in BusinessNumber of Full and Part-Time employeesCities you servicePlease enter cities, separated by comma. Example: Minneapolis, St. Paul, BloomingtonCounties you servicePlease enter counties, separated by comma. Example: Hennepin, Ramsey, WashingtonStates you servicePlease enter states, separated by comma. Example: Minnesota, Wisconsin, IowaWhat types of services do you provide?*Check all that apply Electrical Floor Care General Maintenance/Handyman HVAC Janitorial Lawn Care Plumbing Snow Removal Other Describe Other Business Ownership Questionnaire Tegrete is required to collect Diverse Supplier Business Ownership status from our service providers. This information is used by Tegrete and our clients to track the use of and spending with diverse suppliers. We do not share your specific information, rather information is shared at an aggregate level. It is Tegrete’s practice to subcontract with minority, woman, disabled, veteran, and LGBTQ owned businesses for products and services to the maximum practical extent in the performance of our contracts. Therefore, your completion of this questionnaire is greatly appreciated. While certification is not required to do business with Tegrete, we strongly recommend certification so that you can become part of our Supplier Diversity program. Tegrete will require diverse supplier certification from a recognized third party certification organization. Tegrete does not recognize self-certification.Is at least 51% of your business owned and managed by a woman?* No Yes Opt Out Is at least 51% of your business owned and managed by a minority?* No Yes Opt Out Select the applicable description* Asian-Indian Asian-Pacific Black Hispanic Native American Other Is at least 51% of your business owned and managed by a veteran?* No Yes Opt Out Is at least 51% of your business owned and managed by a disabled person??* No Yes Opt Out Is at least 51% of your business owned and managed by a LGBTQ person??* No Yes Opt Out Does your business hold any woman, minority, veteran, disabled or LGBTQ certifications?* No Yes Opt Out If yes, please attach supporting documentationIf you are certified minority (MBE), women (WBE), service-disabled (SDV) or veteran – owned (VBE) businesses, please upload proof of certification. Drop files here or Select files Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 10 MB, Max. files: 5. Additional Information Please answer the questions belowDo you have Commercial Liability Insurance and can you provide a Certificate of Insurance?*If yes, please attach COI, if available, at the bottom of this page. No Yes If no, are you willing to obtain Commercial Liability Insurance?* No Yes Do you have Commercial Auto Insurance, or the equivalent, and can you provide a Certificate of Insurance?*If yes, please attach COI, if available, at the bottom of this page. No Yes If no, are you willing to obtain Commercial Auto Insurance?* No Yes Do you have Workers Compensation Insurance and can you provide a Certificate of Insurance?*If yes, please attach COI, if available, at the bottom of this page. No Yes If no, are you willing to obtain Workers Compensation Insurance?* No Yes Do you conduct background screening for yourself and/or your employees?* No Yes If no, are you willing to conduct background screening for yourself and/or your employees?* No Yes Do you conduct drug screening for yourself and/or your employees?* No Yes If no, are you willing to conduct drug screening for yourself and/or your employees?* No Yes Do you use subcontractors to perform services?* No Yes Please note, if you are awarded a contract with Tegrete, your first payment will not be made until all required documentation, including insurance and background screening (if applicable), has been received.Upload Certificate of Insurance files Drop files here or Select files Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 10 MB. Optional InformationPlease provide any additional information you want us to know about your company Client Confidentiality Agreement This Client Confidentiality Agreement (“Agreement”) is entered into by and between the undersigned service provider (“Service Provider”) and Tegrete Corporation (“Tegrete”), for the benefit of Tegrete and Tegrete’s client(s) at whose facilities Service Provider may conduct activities (each, a “Client” and collectively, the “Clients”). Service Provider acknowledges that in the course of performing services for Tegrete and Tegrete’s Clients, Service Provider may receive, gain access to, or come in contact with, certain Confidential Information (as defined below) of Client. Service Provider agrees that all such Confidential Information is the exclusive property of the Client and that maintaining its confidentiality is critical to the integrity and operations of the Client and Tegrete’s business relationship with each Client. Service Provider further agrees that Tegrete’s willingness to engage Service Provider to perform services for the Client’s is contingent upon Service Provider’s willingness to enter into this Agreement. Accordingly, Service Provider agrees to the following terms: Definition of Confidential Information For the purposes of this Agreement, “Confidential Information” includes, but is not limited to: Client Materials. Any and all non-public documents, notes, files, records (electronic or physical), oral information, and other materials related to: the Client’s mission and activities; strategic plans; computer programs; passwords and usernames; financial information; business policies, procedures, and techniques; research or development projects or results; trade secrets; customer lists, customer health information, and information maintained about Client’s donors, prospective customers, and prospective donors and customers, contractors, professional advisors, employees and volunteers; and any information about Client ‘s suppliers and other business partners. Confidential Information of Third Parties. Any and all information that relates to or is claimed by a customer, prospective customer, supplier, donor, or prospective donor to be such person’s confidential information. Technical and Business Information. Any and all technical data, know-how, or business information disclosed in any form (oral, written, electronic, etc.), including, but not limited to: information relating to research, products, services, software, designs, specifications, drawings, developments, discoveries, inventions, processes, trade secrets, samples, prototypes, facilities, engineering, techniques, distributors, end users, costs, pricing, internal procedures, business and marketing plans or strategies, finances, projections, markets, business trends, business opportunities and other significant and valuable business information, and any other business-related information disclosed in any form, whether marked confidential or reasonably understood to be confidential. Exclusions. Confidential Information does not include information which is: (i) already known to the Service Provider as shown by prior written records; (ii) becomes publicly known through no fault of the Service Provider; (iii) disclosed or made available to Service Provider by a third party who is not breaching any obligation of confidentiality to Client; or (iv) independently developed by Service Provider without reference to the Confidential Information. Service Provider’s Obligations Service Provider shall protect and safeguard the confidentiality of all Confidential Information with at least the same degree of care as the Client would protect its own Confidential Information, but in no event with less than a commercially reasonable degree of care. Service Provider shall ensure that all of its employees, contractors, or agents who access or receive Confidential Information understand that such Confidential Information is the exclusive property of the Client and must not be used or disclosed except as authorized in writing by Tegrete or Client. Service Provider agrees not to use, disclose, copy, reproduce, or make any notes or records of Confidential Information, except as necessary to perform services under its agreement with Tegrete and only as authorized in writing by Tegrete or Client. Upon the conclusion of services, or upon request by Tegrete or the Client, Service Provider shall promptly return or securely destroy all Confidential Information and related materials and shall not retain any copies, digital or physical. Service Provider shall also confirm such return or destruction in writing if requested. The obligations of Service Provider set forth in this Agreement shall survive the termination of Service Provider’s engagement and shall remain in effect in perpetuity. Remedies and Enforcement Service Provider understands that a violation of this Agreement likely will result in disciplinary action, including the possible termination of Service Provider’s contract(s) with Tegrete. Service Provider further understands that Tegrete and/or Client reserve the right to pursue legal remedies, including injunctive relief and the recovery of damages. This Agreement shall be governed by and construed and enforced in accordance with the laws of the State of Minnesota without regard to principles of conflicts of law. Any failure by Tegrete to enforce any provision of this Agreement shall not be deemed a waiver unless agreed to in writing and signed by Tegrete, and then only in the specific instance and for the specific purpose given. In addition to the provisions set forth in this Agreement and not as a limitation thereof, Service Provider agrees to indemnify, defend and hold harmless Tegrete from and against any and all damages, costs, liabilities, actions, awards, judgments, allegations or other claims made by Client (including its owners, officers, directors, employees or other persons which may initiate any claims) arising out of or relating to the Service Provider’s breach of this Agreement. ACKNOWLEDGEMENT By signing below, the Service Provider agrees to the terms and conditions outlined in this Agreement and affirms its commitment to protecting the confidentiality of the Client’s information. By placing a check in the box below you acknowledge that you have read and agree to the Tegrete Client Confidentiality Agreement* I have read and agree to the Tegrete Client Confidentiality Agreement Acknowledgement All information provided is true and correct to the best of my knowledgeDigital Signature (please initial)*By initialing this you agree that the information provided is accurate. Δ