Vendor Authorization Form – Clean Water of New York, Inc

Vendor Name(Required)

Vessel or Tug Name(Required)

Vendor’s Contact Name:(Required)

Vendor’s Contact Title:(Required)

Telephone(Required)

Email Address

Requested Date of Access/Use:(Required)

If Unknown Send list Prior to service. Send Email To: Plant@cwofny.com

Employee/Contractor Name #1

Have TWIC?

Yes

Employee/Contractor Name #2

Have TWIC?

Yes

Employee/Contractor Name #3

Have TWIC?

Yes

Employee/Contractor Name #4

Have TWIC?

Yes

Specific areas requiring service

Compartment number(s)

Spaces or other areas

Comment or special instructions

By submitting this Vendor Authorization Form, the undersigned, on behalf of the Vendor set forth above, and with its authorization, warrants that:

Vendor has read the terms of the Vendor Authorization available at www.cwofny.com/vendor-authorization-terms-and-conditions (the “Terms”);
accepts and agrees the Terms are expressly made a part hereof;
the authorization contemplated by Vendor’s Application is conditioned upon Vendor’s acceptance and agreement of the Terms;
the Terms impose upon Vendor insurance requirements and indemnification, defense, and hold harmless duties, even for the negligence of Clean Water of New York, Inc., and Vendor agrees and accepts to be bound by those duties and all of the Terms.

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