Vendor Profile Form.pdf

Fill-in Forms Information for the SP-26NB and W-9 Forms

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STATE OF CONNECTICUT - AGENCY VENDOR FORM

IMPORTANT: ALL parts of this form must be completed, signed and returned by the vendor.

READ OMPLETE AREFULLY SP-26NB-IPDF Rev. 4/10 & C C

COMPLETE VENDOR LEGAL BUSINESS NAME Taxpayer ID # (TIN):

SSN FEIN

WRITE/TYPE SSN/FEIN NUMBER ABOVE

BUSINESS NAME, TRADE NAME, DOING BUSINESS AS (IF DIFFERENT FROM ABOVE)

BUSINESS ENTITY: CORPORATION LLC CORPORATION LLC PARTNERSHIP LLC SINGLE MEMBER ENTITY

NON-PROFIT PARTNERSHIP INDIVIDUAL/SOLE PROPRIETOR

NOTE: IF INDIVIDUAL/SOLE PROPRIETOR, INDIVIDUAL’S NAME (AS OWNER) MUST APPEAR IN THE LEGAL BUSINES

BUSINESS TYPE: A. SALE OF COMMODITIES B. MEDICAL SERVICES C. ATTORNEY FEES D. R

(R

E. OTHER (DESCRIBE IN DETAIL)

UNDER THIS TIN, WHAT IS THE PRIMARY TYPE OF BUSINESS YOU PROVIDE TO THE STATE? (ENTER LETTER FROM

UNDER THIS TIN, WHAT OTHER TYPES OF BUSINESS MIGHT YOU PROVIDE TO THE STATE? (ENTER LETTER FROM

NOTE: IF YOUR BUSINESS IS A PARTNERSHIP, YOU MUST ATTACH THE NAMES AND TITLES OF ALL PARTNERS TO Y

NOTE: IF YOUR BUSINESS IS A CORPORATION, IN WHICH STATE ARE YOU INCORPORATED?

VENDOR ADDRESS STREET CITY STA

Add Additional Business Address & Contact information on back of this form.

VENDOR E-MAIL ADDRESS

VENDOR WEB SITE

REMITTANCE INFORMATION: INDICATE BELOW THE REMITTANCE ADDRESS OF YOUR BUSINESS. SAME AS VENDO

REMIT ADDRESS STREET CITY STA

CONTACT INFORMATION: NAME (TYPE OR PRINT)

1ST BUSINESS PHONE: Ext. # HOME PHONE:

2ND BUSINESS PHONE: Ext. #� 1ST PAGER:

CELLULAR: 2ND PAGER:

1ST FAX NUMBER:� TOLL FREE PHONE:

2ND FAX NUMBER:� TELEX:

WRITTEN SIGNATURE OF PERSON AUTHORIZED TO SIGN PROPOSALS ON BEHALF OF THE ABOVE NAMED VENDOR

SIGN HERE

TYPE OR PRINT NAME OF AUTHORIZED PERSON

TITLE OF AUTHORIZED PER

IS YOUR BUSINESS CURRENTLY A DAS CERTIFIED SMALL BUSINESS ENTERPRISE? YES (ATTACH COPY OF CE

IS YOUR BUSINESS CURRENTLY A CT DOT CERTIFIED DISADVANTAGED BUSINESS ENTERPRISE (DBE)? YES

IF YOU ARE A STATE EMPLOYEE, INDICATE YOUR POSITION,

AGENCY & AGENCY ADDRESS

PURCHASE ORDER DISTRIBUTION:

(E-MAIL ADDRESS)

NOTE: THE E-MAIL ADDRESS INDICATED IMMEDIATELY ABOVE WILL BE USED TO FORWARD PURCHASE ORDER

ADD FURTHER BUSINESS ADDRESS, E-MAIL & CONTACT INFORMATION ON SEPARATE SHE

G

OVERNMENT

S NAME BLOCK ABOVE.

ENTAL OF PROPERTY

EAL ESTATE & EQUIPMENT)

ABOVE) ➝

ABOVE) ➝

OUR BID SUBMISSION.

TE ZIP CODE

R ADDRESS ABOVE.

TE ZIP CODE

DATE EXECUTED

SON

RTIFICATE) NO

NO

S TO YOUR BUSINESS.

ET IF REQUIRED

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