SAMPLE VENDOR REGISTRATION FORM

YOUR LOGO

Company Name
Address Line 1
Address Line 2
Phone | Fax
email

VENDOR REGISTRATION FORM

INTERNAL USE ONLY	VENDOR ID	DATE

TRADE CATEGORY
Define the type of contractor work your company performs. If you are a vendor, please describe what you supply.

COMPANY NAME

CONTACT
NAME	TITLE
ADDRESS
PHONE	EMAIL
FAX	WEBSITE

SCOPE OF WORK
Please provide additional details regarding the offerings of your organization.

ORGANIZATION
NUMBER OF YEARS IN BUSINESS
CLASSIFICATION / CERTIFICATION
ORGANIZATION TYPE
UNION AFFILIATIONS
TAXPAYER ID NUMBER	FEDERAL TAX ID NUMBER	– OR – SOCIAL SECURITY NUMBER
Please list the cities and/or states that your company performs work in.

AUTHORIZATION FOR DIRECT DEPOSIT OF SUPPLIER PAYMENTS
NAME OF BANK / CREDIT UNION
BANK / CREDIT UNION ROUTING NUMBER
CHECKING ACCOUNT NUMBER *

*Savings account numbers may not be used.

I hereby authorize:

1) [ENTER COMPANY NAME] to deposit my supplier invoice payment via electronic funds transfer.

2) my financial institution to credit this amount to my account.

In the event that the exercise of this authorization (for any reason) results in an overpayment for supplier invoices actually due and payable to me, I hereby authorize the payer to either: A) debit my above-identified account for an amount not to exceed said overpayment; or B) withhold a sum equal to the overpayment from the next disbursement of my supplier invoice payment.

CERTIFICATION

I hereby affirm that all information supplied is true and accurate to the best of my knowledge and belief, and I understand that this information will be considered material in the evaluation of quotations, bids, and proposals. Notice must be given of any change in status impacting the information provided within ten (10) days of said change.

NAME	TITLE
SIGNATURE	DATE

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