Vendor_Packet_with_ACH_form_2025.pdf

Onslow Water & Sewer Authority Finance Office

228 Georgetown Road Jacksonville, NC 28540

Fax (910) 455-2504

Name (as reported on your income tax return)

Business Name Vendor# (to be assigned)

Federal ID# __________________________________ OR

SS#

Check one of the following:

Corporation Sole Proprietorship Partnership Other

Order Address Payment Address

Street Street

PO Box PO Box

City City

State State

Zip Code Zip Code

Contact Person Contact Person

Phone Number Phone Number

Fax Number Fax Number

Terms Discount

E-Mail Address

Are you related to or have a professional relationship with any ONWASA employee? Yes No

(If you answered yes, a Relationship Vendor form must be completed before any payments can be made.) Are you a minority business enterprise? Yes No

If you responded yes, please check the appropriate box:

African American Hispanic American Indian Female Asian American Socially and economically disadvantaged as defined in 15 U.S.C. 637

Products and Services

Please list the type of product(s) and/or service(s) that your company can provide:

Signature:

Title:

Onslow Water and Sewer Authority 228 Georgetown Rd. Jacksonville, NC 28540

ACH AUTHORIZATION FORM

Vendor Information

Vendor Name (Include DBA if applicable)

Address City ST Zip

Accounting/ACH Contact Name

Phone

Email Address for Remittance Advice (**required**)

Bank Information

Account Type Checking Savings Name on Bank Account

Name of Bank

Bank Routing Number Bank Account #

Above named Vendor hereby authorizes Onslow Water and Sewer Authority to originate Automated Clearing House electronic funds transfer (EFT) credit entries to Vendor's account, as indicated above, for payment/ reimbursement of goods and/or services If you change banks or accounts please provide at least thirty (30) days written notice.

**A Bank Information Letter with the above details substitutes for completing this form.**

Vendor Authorization:

Authorized Name/Title Authorized Signature Date

Accounts Payable Use: Date Received: Date Entered: Entered by:

Onslow Water & Sewer Authority

Finance Office

228 Georgetown Road Jacksonville, NC 28540

Fax (910) 455-2504

Relationship Vendor Form

If you are related to or have a professional relationship with any employee of Onslow Water and Sewer Authority, this form must be completed and returned to the finance office before any payments will be made.

Simply ignore this form if it does not apply to you.

Vendor Information:

Name:

Address:

Related ONWASA employee:

Relationship to employee:

We agree that our relationship will not hinder or corrupt our professional relationship with Onslow Water & Sewer Authority.

Vendor Signature Date

ONWASA Employee Signature Date

Onslow Water and Sewer Authority is aware and understands these parties have a relationship with each other. The decision to authorize the use of this vendor was not influenced in any manner by the relationship referenced above.

Department Head Date

Finance Officer Date

E-VERIFY AFFIDAVIT

I, _______________________ (the individual attesting below), being duly authorized by and on behalf of

_________________________ (the entity identified as the "Employer") after first being duly sworn, hereby swear or affirm as follows:

1. Employer understands that E-Verify is the federal E-Verify program operated by the United States

Department of Homeland Security and other federal agencies, or any successor or equivalent program used to verify the work authorization of newly hired employees pursuant to federal law in accordance with NCGS §64-

25(5).

2. Employer understands that Employers Must Use E-Verify. Each employer, after hiring an employee to work in the United States, shall verify the work authorization of the employee through E-Verify in accordance with NCGS§64-26(a).

3. Employer is a person, business entity, or other organization that transacts business in this State and that employs 25 or more employees in this State.

Employer employs the following number of employees in this State (check which is applicable):

a. Less than 25 _______ b. Between 25 and 100 _______

c. Between 100 and 500 _______ d. 500 or more _______

4. Employer will ensure compliance with E-Verify by any subcontractors subsequently hired by Employer for specified contracts subject to E-Verify entered with the Onslow Water & Sewer Authority Employer.

This _______ day of _____________________, _________.

Signature of Affiant _______________________________.

____________________________________Notary Use Only Below___________________________________

State of _____________________________

County of ____________________________

Signed and sworn to (or affirmed) before me, this the _____ day of _____________________, _______.

Notary Print Name _______________________________

Notary Public Signature ___________________________

My Commission Expires: __________________________

(A ffix

O fficial/N o tarial

S eal)