New_Vendor_Application_(1).pdf

City of Kingman Date:

New Vendor Application

Company Name Contact Person/Title

Address City State Zip Code

Payment Remittance Address City State Zip Code

Billing Contact Phone Email

Valid Arizona Contractor License DUNS number (register at www.sam.gov)

Name Title Phone Email

Name Title Phone Email

Individual/Sole Proprietor Attorney

Rent/Royalties LLC

YES NO Employee Name/Position

Print Name

Title Date

Vendor Number: Date Processed: Initials:

City of Kingman Finance Signature: Date:

I hereby certify that the above information is true and correct to the best of my knowledge. I understand that the submission of false or inaccurate information may result in rejection or deletion of my application.

Vendor Application

Health Care Provider

Authorized Individual's Signature

Individual(s) authorized to contractually bind the company or firm (Please indicate if agent):

Other:_____________________

TYPE OF BUSINESS: 1099 Required? YES NO

For purposes of determining any possible conflict of interest, all Vendors must disclose if any current City of Kingman employee is also an owner, corporate officer, or employee of your business. Indicate either Yes (a City of Kingman employee is associated with your business), Or No. If yes, provide the name(s) of the City of Kingman employee and the position they hold within your business.

Please provide all information requested on this application form. Please insert N/A for items not applicable:

IF YOU ARE A CONTRACTOR LICENSED UNDER THE ARIZONA REGISTRAR OF CONTRACTORS, YOU MUST

PROVIDE THE FOLLOWING

Office Use Only

Additional Notes/Comments:

Company Website:

Please return completed application and W-9 to vendors@cityofkingman.gov If you have any further questions or need any assistance, please contact our accountant:

Alicia Price - (928)-753-8106 - Vendors@cityofkingman.gov

TPT Number:

City of Kingman Business License Holder? YES NO If yes, License #:

swarner Sticky Note Typed signatures not accepted. Please sign and scan back or digitally sign with timestamp.