Vendor Interest Form

Please provide the following information about your business

* Vendor Business Name:

* Contact First and Last Name:

* Vendor website address or Facebook page URL:

* Vendor Email:

Vendor Phone Number (000) 000-0000:

* Vendor Address:

* Are you a Food Truck vendor?:

Yes

* If you indicated no, please specify what type of vendor you are:

Fill in your Southern Nevada Health Permit Number, if applicable:

* Indicated your SNHD grade?:

Pass

N/A

* Fill in your City of Henderson Business License Number:

* Nevada Sales Tax ID Number:

* Indicate which of the following insurances you have (please check all that apply):

Auto Liability (owned/non owned) $500,000/ $1,000,000 Bodily Injury

Commercial General Liability (CGL) | $1,000,000 Occurrence | $1,000,000 Personal Injury | $1,000,000 General Aggregate

Workers Compensation (Statutory Limits)

* Denotes Required Field

*Please note you will need to provide a Certificate of Insurance (COI) listing Inspirada/CCMC as a certificate holder, and both Inspirada/CCMC and City of Henderson as “Additional Insured”.

Thank you for your interest in becoming a vendor at Inspirada. You have been added to our vendor database and will be contacted when opportunities are available. Partially completed forms may be rejected.

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