Vendor-Information-Request-Form-fillable.pdf
PDF 186 KB Posted
- Solicitation number
- RFP-SM-0111
- 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 engagement. The form captures essential company information including legal name, contact details, addresses, tax classification (listed as Individual/Sole Proprietor), and payment terms (1% 10 - 1% 10 DAYS; NET 30 DAYS). The form includes sections for W-9 information, accounts receivable details, purchase order address, and a section for vendors to indicate Small Business Enterprise certification status.
The form provides flexibility for new vendor registration or updating existing vendor information, with designated areas for contact information, remittance details, and certification specifics. West Basin Municipal Water District's standard payment terms are Net 30, and the form allows vendors to provide multiple contact points and addresses for different purposes such as accounts receivable and purchase order communication. The document includes checkboxes for indicating whether the vendor is a Certified Small Business Enterprise and provides space for multiple certification agency and number entries, suggesting the district's potential interest in supporting diverse or small business vendors.
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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: |
File details come from the government source that posted it. Updated .