Firm Name: UBI Number: Contact: Day Phone Number: Night Phone Number: Fax: Email: Website: Address: Line 2: City: State: Zip:

Remit Address (if different)

Line 1: Line 2: Categories:

My firm wishes to be added to the small purchase roster for the categories as indicated by the boxes I have checked above.

I understand that it is my firm's responsibility to keep abreast of current requirements and notices posted to the Kittitas County Purchasing website regarding the Small Purchase Rosters and Kittitas County is not responsible for communicating changes or amended requirements by the State to the firm.

Submitted by: Title: Date: