Vendor_Information_Request_Form-fillable.pdf

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

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