Vendor-Information-Request-Form-fillable.pdf
PDF 186 KB Posted
- Solicitation number
- RFP-SM-0108
- Issued by
- Los Angeles County, California
About this file
This document is a Vendor Information Request form from the West Basin Municipal Water District, designed to collect comprehensive vendor details for potential business relationships. The form covers multiple sections including company information, W-9 information, accounts receivable details, purchase order address, and vendor small business enterprise information. It provides spaces for vendors to enter their complete legal name, contact information, tax classification, federal tax ID, remittance details, and certification status as a small business enterprise. The form allows for both new vendor entries and changes to existing vendor information, with a payment terms section indicating 1% 10 - 1% 10 days, with net 30 days being the standard West Basin terms. The form is structured to capture essential vendor data for the municipal water district's purchasing and accounts payable processes, including options to verify small business enterprise certifications with public agencies.
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Text version
Entered By:
City/State/Zip:
Contact Email:
Tax Classification:
Contact Phone:
Contact Name:
How long at this address? Contact Email:
Payment Discounts:
(West Basin terms are Net 30)
Contact Fax:
Contact Email:
Which Public Agency are you Certified With :
Certification Number:
Print Name:
Contact Phone:
Certification Number:
City/State/Zip:
Address 2:
City/State/Zip:
Are you a Certified Small Business Enterprise? If yes, please provide the following information:
Address 1:
W-9 Received:
Which Public Agency are you Certified With :
Contact Fax:
COMPANY INFORMATION
Contact Name:
Contact Fax:
Address 1:
Address 1: Contact Phone:
Address 2:
Remittance name:
VENDOR INFORMATION REQUEST - West Basin Municipal Water District
Requested By: Request Date: Request:
Complete Legal Name:
Address 2:
PURCHASE ORDER ADDRESS (WHERE PURCHASE ORDER IS SENT)
Signature:
Federal Tax ID #:
W-9 INFORMATION
By signing, you authorize West Basin to verify the information stated on this form.
Title:
Box 1:
Date:
ACCOUNTS RECEIVABLE (REMITTANCE NAME AND ADDRESS)
VENDOR SMALL BUSINESS ENTERPRISE INFORMATION
Vendor Number:
FOR PURCHASING ONLY
Which Public Agency are you Certified With :
Certification Number:
Yes No
New
NoYes
ChangeNew
Sheet1
| Complete Legal Name: |
| Address 1: |
| Contact Phone: |
| Address 2: |
| Contact Fax: |
| CityStateZip: |
| How long at this address: |
| Contact Email: |
| Title: |
| Print Name: |
| Federal Tax ID: |
| Remittance name: |
| Contact Name: |
| Address 1_2: |
| Contact Phone_2: |
| Address 2_2: |
| Contact Fax_2: |
| CityStateZip_2: |
| Contact Email_2: |
| Address 1_3: |
| Contact Name_2: |
| Address 2_3: |
| Contact Phone_3: |
| CityStateZip_3: |
| Contact Fax_3: |
| Contact Email_3: |
| Which Public Agency are you Certified With: |
| Certification Number: |
| Which Public Agency are you Certified With_2: |
| Certification Number_2: |
| Which Public Agency are you Certified With_3: |
| Certification Number_3: |
| Entered By: |
| Vendor Number: |
| Box_1: [N/A] |
| Tax Classification: [Individual/Sole Proprietor] |
| Payment Discounts: [1%10 - 1% 10 DAYS; NET 30 DAYS] |
| Small Business_Yes: Off |
| Small Business_No: Off |
| W9 Received_Yes: Off |
| W9 Received_No: Off |
| Request_New: Off |
| Request_Change: Off |
| Request Date: |
| Date Entered: |
| Requested By: |
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