Vendor_Form_Fillable_Revised_3_20_2024.pdf

Select one of the above

Remittance Name

Address P.O. Box or Street Address

City State Zip

Tel Fax: Contact

Email

Federal I.D. No. - Social Security No_______-______-________

Name on Checks Name on Checks Required

Vendor Name

Address P.O. Box or Street Address

City State Zip

Country Tel Fax

Contact Email

Web Address

Vendor Name

Address P.O. Box or Street Address

City State Zip

Tel Fax Contact

Email address Web Address

►►NOTE: ALL ABOVE SECTIONS MUST COMPLETED AND INCLUDE A CONFIRMATION OR

REGISTRATION FROM HTTPS://DOS.MYFLORIDA.COM AND W-9 FORM, OPTION FOR ACH PAYMENT.

NOTE: COMPLETION INSTRUCTIONS: Clear copies, incomplete forms will not be accepted. Please complete these forms and return by either Mail, Fax or Email to address as instructed by the requesting individual: Attention

Updated 11/2022

NEW -CHANGE- VENDOR #VENDOR INFORMATION FORM

VENDOR AUTHORIZED SIGNATURE MUST have signature!

Vendor Signature: ___________________________ Date

Display Purchase Order Information

Display Vendor Bid Information https://dos.myflorida.com/

. Vendor: Describe what type of services you provide below; include commodity codes.

FOR CITY STAFF USE ONLY: Must be completed by City Staff only!

Please use the H.T.E or the City's intranet to get the commodities and sub-commodities write the number below that pertains to this vendor submit this with your vendor form. Incomplete forms will be forwarded to the appropriate departments. Thank you, Purchasing Division.

Commodity Sub-Commodity

Must be completed by the Department:

Requested by ______________________________________________________________________________

Dept./Division __________________________________________________ Date: ____________________

Electronic Funds Transfer (EFT) Enrollment Form If you wish to enroll in EFT, you MUST fill out the below information.

Vendor Name:

Email address: __________________________________________

Bank Name: _______________________

ACH Routing # Account #_______________________________

☐ Checking Account ☐ Saving Account

Email address used for payment notifications: Required

The first biweekly EFT will be a PRE-NOTE, which will be sent to the above email address with a zero balance. Please provide the City with an updated email address should you have any staff changes in the future.

FOR CITY STAFF USE ONLY

Changes to the ACH account must be verbally communicated with the Vendor by a Purchasing Agent

Name and Title (Vendor Information)

Vendor Phone Number

Purchasing Agent (Name) Date

\\SAN-CH-PRN\Finance_Dept\Purchasing\A-Purchasing Docs\Vendor Info_Tax Exempt_CityW9 Revised 3/20/2024 file://SAN-CH-PRN/Finance_Dept/Purchasing/A-Purchasing%20Docs/Vendor%20Info_Tax%20Exempt_CityW9