Vendor-Information-Request-Form-fillable.pdf
PDF 186 KB Posted
- Solicitation number
- IFQ-SM-0112
- 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 various information sections including company information, W-9 details, accounts receivable information, purchase order address, and small business enterprise status. The form allows vendors to provide their complete legal name, contact information, tax classification (listed as Individual/Sole Proprietor), and payment terms, which are specified as 1% 10 - 1% 10 DAYS; NET 30 DAYS.
The form includes optional sections for vendors to indicate if they are a Certified Small Business Enterprise, with space to list certification details from public agencies. There is a section specifically for purchasing personnel to enter vendor information, including a checkbox to indicate whether this is a new vendor entry or a change to an existing vendor record. The document provides multiple address fields for remittance, purchase orders, and contact information, demonstrating a structured approach to vendor onboarding and management by the West Basin Municipal Water District.
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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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