AP-TMP-01 Vendor Authorization Request Template.pdf

VENDOR AUTHORIZATION REQUEST

It is the policy of ASRC Federal and its Subsidiaries that all businesses with a qualified SBA certificate* have the maximum practicable opportunity to participate in the performance of contracts awarded by ASRC.

To comply with this policy, please provide the following information:

*SBA Certificates include but are not limited to: Certified Small businesses, Small Disadvantaged businesses (SDB), Woman-owned Small businesses (WOSB), HUBZone businesses and Veteran/Service-Disabled Veteran owned (SDV) small businesses

Request Type:

New Vendor

Vendor Number: Change to Existing Vendor:

Name/Tax ID Address Banking

Name and Address Information:

Legal Name: Doing Business As:

Street Address: Suite #:

City: State: Zip Code:

Website:

Contact Name: Contact’s Title:

Phone: Fax: Email:

Remittance address (if different from the above):

Street Address: Suite #:

City: State: Zip Code:

Business Information:

Taxpayer Identification Number:

(select and enter only ONE) EIN or SSN

Are you eligible to receive a 1099-NEC? No Yes

Parent Company Information: N/A YES Parent Name: Parent TIN:

DUNS Number: Cage Code:

Primary North American Industry Classification System (NAICS) Codes:

Business Type/Size:

Small Business Large Business Foreign-Owned Non-Profit

Tax Classification:

Individual / Sole Proprietor Corporation

Governmental Entity Other (specify):

LLC:

Partnership C Corporation S Corporation Sole-Member

(All new Vendors MUST include a signed IRS form W-9 for setup: IRS Form W-9)

AP-TMP-01 Rev 01 04/01/22

Unique Entity ID (UEI):

https://www.irs.gov/pub/irs-pdf/fw9.pdf

Federal Supplier Certifications: (Check all that apply) Complete the following section with classification status as defined in Federal Acquisitions Regulations (FAR) 19.1.

Woman-Owned Small Business (WOSB)

Minority-Owned Business (complete section below)

Certified Small Business (according to SBA criteria)

HUBZone Cerified

SBA Certified Disadvantaged Business (SDB)

Veteran-Owned Business

Service-Disabled Veteran Owned (SDV)

Historically Black College/Minority Institution (HBCU)

Minority Ownership:

African American

Native American

Other

Asian Pacific American

Subcontinent Asian American

Hispanic American

Alaskan Native Corporation

Payment Terms:

ASRC Federal defaults to Net 45 a payment term for large business and Net 30 for small business, unless stated otherwise in the sales contract

Title

Date ASRC Federal and its Subsidiaries (ASRC) may award procurement to the seller where the costs will be charged to a U.S. government prime or subcontract. If so, the seller is advised that the U.S. government may impose a penalty against a firm misrepresenting its business size and/or disadvantaged status for the purposes of obtaining procurement that is to be included as part, or all of a goal contained in ASRC’s Subcontracting plan. Eligibility as a small business is based on the regulations issued by the Small Business Administration in CFR 13, Part 121 of the SBA Rules and Regulations and FAR 52.219-1.

Authorized Representative Signature (Certified Digital Signature or Wet Ink Only)

Printed Name

For Internal Use Only

Requester Name:_____________________ Requester Signature:__________________________ Date:__________

Vendor Number:_____________ Completed By:____________________________________ Date:__________

ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENT

Instructions for Payee:

1. Fill in all fields legibly and completely.

2. Attach one of the following confirming the information below as supporting documentation:

- A voided check

- Letter from financial institution (letter must be issued and signed by your financial institution and include your banking information)

3. Authorized owner/payee must sign and date form. Certified Digital Signature or Wet Ink Only Business accounts require all bank signatures necessary to be on this form. If additional lines are needed, please attach an additional sheet.

4. Submit completed, signed form along with supporting documentation to Vendor.Requests@ASRCFederal.com.

Requested Action: (Please check appropriate box) New Banking Setup Add Additional Bank

Change in Bank Information (previous banking information is REQUIRED to update banking):

Previous Banking Information on file:

Payee Information:

Taxpayer Identification Number:

(select and enter only ONE) or SSN

Legal Name of Business: Name on Bank Account: (if different than Legal Name)

Street Address: Suite #:

City: State: Zip Code:

Contact Name: Contact Title:

Phone: Fax: Email:

Financial Institution Information:

Financial Institution Name:

Street Address: Suite #:

City: State: Zip Code:

Routing Transit Number: Type of Account: Checking

Savings Bank Account Number:

Additional Information (if applicable):

Authorization:

I hereby authorize ASRC Federal Holding Company and its Subsidiaries, hereinafter referred to as “the Company,” to initiate Electronic Funds Transfer, (EFT), credit entries or debit corrections or all amounts payable to me through the Company’s EFT program(s), and to the depository institution and account, identified above.

This authorization is to remain in full force and effect until the Company has received proper written notification from me of its change or termination, or the Company terminates its EFT program or my participation therein.

Authorized Representative Signature Date

Printed Name/Title

EIN

For Internal Use Only

Requester Name:_____________________ Requester Signature:__________________________ Date:__________

Vendor Number:________________ Completed By:____________________________________ Date:__________

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