MT_SAC_VENDOR_PACKET_(5).pdf

Mt. San Antonio College Purchasing Department 1100 N. Grand Ave.

Walnut, CA 91789

Phone (909) 274-4245 Fax (909) 274-2025

VENDOR INFORMATION

1. GENERAL INFORMATION

Company Name

Contact Name dba (if applicable)

Mailing Address

City, State & Zip Code

Phone Number Fax Number

E-Mail Address

Website Address

2. Remittance Address (If different from Item 1):

Company Name

Contact Name dba (if applicable)

Mailing Address

City, State & Zip Code

Phone Number Fax Number

E-Mail Address

Alternate E-Mail Address

3. Affirmative Action (Check One):

Minority-Owned/Disadvantaged Business Woman-Owned Business Small Business Concern Disabled Veteran Enterprise Other___________________________________ None of the Above

4. ACH Info:

Bank Name: __________________________________

Routing # : ___________________________________

Account Name: ________________________________

Account # : ___________________________________

Account Type: ____Checking ____Savings

Does an employee or officer of Mt. San Antonio College own, partly own, operate, or have a financial interest in this business? Yes No If yes, please provide the name of the Mt. San Antonio College employee or officer who is affiliated with this business. _________________________________________________

DISTRICT USE ONLY

VENDOR I.D. NO: DATE ENTERED:

By:

BANK VERIFICATION: DATE VERIFIED:

By:

PRE-NOTE: DATE COMPLETED:

By:

Dear Prospective Vendor, If your address is outside California our college may need one of the additional forms below.

To assist you in determining which form to submit, below are brief form descriptions:

Form 590 withholding exemption certificate: to be used if a company is claiming an exemption from withholding i.e. they have a presence in California

Form 588 Nonresident Withholding Waiver Request: to be used if a company is requesting a withholding waiver i.e. they are filing a California Tax Return for reason(s) listed on the form

Form 587 Nonresident Withholding allocation Worksheet: to be filled out by a company if the other two forms are not applicable i.e. the company does not have a presence (address) in California and are not filing California tax returns

Attached are additional forms that your company will need to review.

Please choose one and send back with W9 and company information. Thank you.