Vendor Setup Form Survey

Question Title

* 1. For which of the following companies are you registering as a supplier

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* 2. Accounts payable contact and payment address

Name *

Company

Address *

Address 2

City *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. Legal business name
(as shown on business tax return)

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* 4. Registered DBA, if different than legal business name

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* 5. Type of business entity

Individual/sole proprietor

Partnership

LLC

Corporation (including LLCs electing to be taxed as S-Corp or C-Corp)

Registered Nonprofit organization [501(c)(3), etc.]

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* 6. Taxpayer ID (SSN or FEIN)
The Taxpayer Identification Number must match the name given, as shown on your tax return, to avoid backup withholding.

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* 7. Please indicate if any of the following categories apply to your
business

Attorney or legal firm

For-profit medical service

Rent

Royalties

No, my business is not one of the above categories

This vendor setup form is a Substitute W9. Pursuant to Internal Revenue Service Regulations, you must furnish your Taxpayer Identification Number (TIN) to us in order to receive payments from us. If this number is not provided, you may be subject to a 24% withholding on each payment. To avoid this 24% withholding and to insure that accurate tax information is reported to the Internal Revenue Service, please use this form to provide the requested information.

If you are an individual, you must furnish your individual name as shown on your social security card on this form. If you have changed your last name, for instance, due to marriage, without informing the Social Security Administration of the name change, and you are invoicing us using your Social Security number, please enter your first name, the last name shown on your Social Security card, and your new last name.

If you are a sole proprietor, you must furnish your individual name as shown on your Social Security card, and either your SSN or EIN (Employer Identification Number) if others will be using it for claims payment. You may also enter your business name or “doing business as” name on the business name line.

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* 8. IRS Required Certifications – Under penalty of perjury, I certify that:

1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3) I am a US citizen or other US person.

Vendor Setup Form

Question Title

* 1. For which of the following companies are you registering as a supplier

Question Title

* 2. Accounts payable contact and payment address

Question Title

* 3. Legal business name(as shown on business tax return)

Question Title

* 4. Registered DBA, if different than legal business name

Question Title

* 5. Type of business entity

Question Title

* 6. Taxpayer ID (SSN or FEIN)The Taxpayer Identification Number must match the name given, as shown on your tax return, to avoid backup withholding.

Question Title

* 7. Please indicate if any of the following categories apply to yourbusiness

Question Title

* 8. IRS Required Certifications – Under penalty of perjury, I certify that:

* 3. Legal business name
(as shown on business tax return)

* 6. Taxpayer ID (SSN or FEIN)
The Taxpayer Identification Number must match the name given, as shown on your tax return, to avoid backup withholding.

* 7. Please indicate if any of the following categories apply to your
business