Vendor Application

Vendor Application FIN-F043 Rev.10-22-04To process your vendor application, ALL fields must be complete.


Federal ID#
 
SS#
 
Federal ID #:
 
Vendor Name:
 
Vendor Name:
 
 
 
Federal ID# or SS# must be provided before payment can be made.
SS#:
 
 
 
Order Address
Federal ID# or SS# must be provided before payment can be made.
 
 
Pay Address
Order Address
 
Address 1
Address 2
City
State
Zip Code
Pay Address
 
Address 1
Address 2
City
State
Zip Code
Email Address:
 
Contact Person:
 
Telephone:
 
 -  - 
(XXX)-XXX-XXXX
Fax:
 
 -  - 
(XXX)-XXX-XXXX
Year Established:
 
Terms:
 
Discount:
 
Contractors License Number (if applicable):
 
Are you incorporated?
 
*WILL YOU ACCEPT PAYMENT BY CREDIT CARD?
 
Women Business Enterprise:
 
Minority Business Enterprise:
 
Disabled Business:
 
 
 
To qualify for M/WBE status, 51 percent of the company must be owned and controlled by minority groups or women. For the purpose of this definition, minority group members are African Americans, Hispanic Americans, Native Americans, Asian Pacific or Asian Indians and American Women.

To qualify for Disabled status, 51 percent of the company must be owned and controlled by disabled persons.
Product(s) and/or Service(s)
Please list the type of product(s) and/or service(s) that your company can provide.
 
Customer Business References
1. Customer Name:
 
Address:
 
Contact Person:
 
Telephone Number:
 
 -  - 
(XXX)-XXX-XXXX
Product/Service Provided:
 
Date Product/Service Provided:
 
Click to View Date Picker
2. Customer Name:
 
Address:
 
Contact Person:
 
Telephone Number:
 
 -  - 
(XXX)-XXX-XXXX
Product/Service Provided:
 
Date Product/Service Provided:
 
Click to View Date Picker
3. Customer Name:
 
Address:
 
Contact Person:
 
Telephone Number:
 
 -  - 
(XXX)-XXX-XXXX
Product/Service Provided:
 
Date Product/Service Provided:
 
Click to View Date Picker
To process your vendor application, ALL fields must be complete.