HTML Preview Vendor Application Form page number 1.
Vendor Application Form
Please complete all of the following information, where applicable:
Tax ID # (FEIN or SSN): ________________________
Organization Type: ( ) Corporation ( ) Individual/Sole Proprietor ( ) Joint Venture
( ) LLC ( ) Partnership/Limited Partnership ( ) Non Profit*
Tax Exempt
Name of Company/Firm (as shown on Federal Tax return): _____________________________________
Alternate name, if applicable (doing business as
): ____________________________________________
Mailing address: _______________________________________________________________________
City: _________________________________ State: ___________________ Zip+4: ________ - ______
Contact person: _____________________________________ Business Ph#: (____) ____ - __________
Fax #: (____) ____ - _____ E-mail address (for E-notifications
): __________________________________
Company / Firm’s website address: _______________________________________________________
Payment address (if different from address above
): _____________________________________________
City: _________________________________ State: ___________________ Zip+4: ________ - _______
Separate Checks: ( ) Yes or ( ) No Accept Purchasing Card (i.e. VISA): ( ) Yes or ( ) No
Business E-mail address (for e-notifications): _________________________________________________
Banking Info: Account #: _________________________________________________________________
Routing and transit # (Via ACH):____________________________________________________________
Are you currently employed or have you ever been employed by FLVS? ( ) Yes or ( ) No
If yes, please specify employment dates:____________________________________________________
Requestor/Vendor’s Signature: _________________________ Date requested/sent: ________________
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____ New Vendor (A completed and signed W-9 form from the vendor (Required))
Vendor Type: ____ V – Standard ____ I – Payroll ____ C – Consultant/Channel Partners
____ Vendor Change (Provide changes below, where applicable
)
Vendor #: ______________________ Date received by Accounting: __________________
Authorized Signature: ____________________________ Date completed:_________________