1-Supplier Create Update.pdf

Louisville Metro Government Office of Management & Budget

Create / Update Supplier Form 3/2023

Create / Update Supplier Form Instructions Form is optional for Non-Procurement Suppliers.

To Request New Supplier: Suppliers complete all sections of this form along with an IRS Form W-9 dated within the last 12 months. Forms are attached and submitted by LMG in Workday as part of the CREATE SUPPLIER REQUEST task.

To Update / Change to Supplier Record: Suppliers must complete the applicable sections. LMG completes the Workday task CREATE REQUEST; select SUPPLIER CHANGE REQUEST; enter the requested change and attach this completed form

Section 1: Supplier Information Supplier Name (Company or Individual) Alternate Name / DBA

Federal Employer ID (TIN/EIN) or Social Security Number TIN/EIN

SSN

Fed Unique Entity Identifier (if applicable) Phone Number Contact First Name Contact Last Name Email Address Address Line 1 Address Line 2 City State Postal Code Remit to Address (if different from above) Address Line 1 Address Line 2 City State Postal Code Supplier Group: Select the group(s) that best describe the type of supplier

Goods and Non-Professional Services Construction Professional Services Non-Procurement

Section 2: Supplier Classification Ownership Status (51% owned or controlled)

Minority-Owned Women-Owned Disabled-Owned LGBT-Owned Non-Profit Not Applicable

Section 3: Certifications (if applicable) Louisville Metro Human Relations Commission Certification Type

Minority Business Enterprise (MBE) Women Business Enterprise (WBE) Disabled Business Enterprise (DIBE) LGBT Business Enterprise (LGBTBE) Veteran Owned Small Business (VOSB) Service-Disabled VOSB (SDVOSB)

Louisville Metro Human Relations Commission Certification Race / Ethnicity American Indian or Alaska Native Asian American Asian-Indian American Asian-Pacific American Black / African American Caucasian Latino or Hispanic Other

Section 4: Authorization By my signature below, I affirm that the organization has authorized me to disclose the information contained herein and hereby further affirm that said information is accurate to the best of my knowledge and belief.

Representative Signature Phone:

Representative Printed Name Date: