Vendor_Entry_Form.pdf

�Add Vendor �Change Vendor Info �Delete Vendor

Business Name:

1099 INFORMATION

Incorporated?

If “NO” Check One:

�YES �NO Federal Tax ID: -

�SOLE PROPRIETORSHIP �PARTNERSHIP �OTHER:

- -If “NO” Enter your Social Security Number:

IRS Reporting Name*:

*If this is not the name listed on contracts with the city, please attach a detailed explanation.

Address:

City:

Phone:

Website Address:

Email Address:

State: Zip:

Fax: ( )( ) Ext.

ORDERING ADDRESS INFORMATION

Check each that applies*:

Address:

City:

Phone:

Contact:

Email Address:

State: Zip:

Fax: ( )( ) Ext.

Title:

*Please attach additional pages if you have more than one ordering/other location.

C of C 81-245

City of Cleveland Justin M. Bibb, Mayor

VENDOR ENTRY FORM

REMITTING ADDRESS INFORMATION

Address:

City:

Phone:

Contact:

Payment Name*:

( ) Ext.

State: Zip:

Fax: ( )

*If payment name is different from business name, please attach a detailed explanation.

BANK INFORMATION

Bank Name:

Bank Contact:

Other questions or issues concerning this form may be addressed to:

Account #:

ABA/Routining #:

IF YOU ARE CURRENTLY RECEIVING PAYMENTS VIA EFT, PLEASE COMPLETE THIS

SECTION TO VERIFY OUR INFORMATION

Phone:

TO BE COMPLETED BY THE CITY OF CLEVELAND

PLEASE DO NOT WRITE IN THIS SECTION

Business Classification:

City of Cleveland Certification Number:

Female Business Enterprise Minority Business Enterprise

�YES �NO �YES �NO

FOB Point:

Discount Payment Terms:

Are Price Breaks Available?

Standard Lead Time:

Standard Shipping Method:

Price Catalogue on disk/CD:

Payment Terms:

Order Minimum:

Line Minimum:

Approved by Commissioner of Accounts Date

C of C 81-245