Supplier Application - ITR Concession Co. LLC.

Suppliers are required to apply all sales taxes applicable to the state of Indiana. This application does not constitute an agreement to do business.

Company Info

Company Name*

Corporate Address*

Street Address Address Line 2 City State ZIP Code

Main Contact Name*

First Last

Main Contact Phone*

Main Contact Email*

Do you want to be setup with a user name and password in order to participate in bid events?*

Yes
No

Does your company have an address different than the corporate address that needs to be shown on purchase orders or contracts?

Yes
No

Sales Contact Name*

First Last

Sales Phone 1*

Sales Phone 2

Sales Contact Email*

Does your company have an address different than the corporate address for payment remittance?

Yes
No

A/R Contact Name*

First Last

A/R Phone*

A/R Contact Email*

Is your company located in a "Hubzone"?

No
Yes

Is your Company a Certified Woman, Minority, Veteran Small Business or Disadvantaged Business? If Yes to any, please attach a copy of your certificate.*

Check all that apply.

No
IDOA WBE
IDOA MBE
IDOA IVOSB
INDOT DBE
Other State DBE
National DBE

Certificate Upload*

Please upload a copy of all certificated indicated in the previous question.

Drop files here or

Do you offer Net45 payment terms?*

Yes
No

If no, what terms do you offer?*

Do you offer early-pay discounts?*

Yes
No

Does your company accept payment by Mastercard credit card?*

No
Yes
Yes, but there is a fee

Additional Documents*

Please upload your completed W9 or W8 and any other pertinent documents (W/MBE certification, line card, ACH payment instructions, location listing).

Drop files here or

Which best describes your supply/service area regarding the Toll Road?*

Local to my city only
From IL border to Elkhart
From Elkhart to OH border
All of road

Choose all services/product categories that apply to your company*

Phone

This field is for validation purposes and should be left unchanged.