Vendor_Registration_Form_2020_(Fillable).pdf

Vendor Registration Form

General Information

Vendor Name (DBA): ___________________________________________ Legal Name: __________________________________________________ Company Description of Services/Goods: ___________________________ Business Type: ☐ Corporation ☐ Non-Corporate ☐ Individual

Main Address:_____________________________________________________ City: ______________________________State: ______ Zip Code:________ County: ____________ Country: ______ Tax ID: ___________________________ Main Contact: _____________________________________ Phone: ___________________________________________ Email: ____________________________________________

1. Minority or Women Owned?

If yes, please select all applicable below:

☐Asian Pacific American ☐African American ☐ Hispanic American ☐Native American ☐Subcontinent Asian American ☐ Non-Minority Woman

2. Veteran Owned?

3. Do you accept Visa Purchasing cards?

4. Is there a fee for using credit cards?

5. Would you be interested in ACH?

6. Would you be interested in ePayables?

Purchase Order Transmission Information Check the box of the preferred means of communication for receiving Purchase Orders. Provide a general email or fax number for all purchase orders to be directed. This should be an email address or fax that is monitored daily.

☐ Email (preferred) _______________________________________ ☐ Fax __________________________________________________

Remit-to Information ☐ Same Address as General Information Remittance Address: _____________________________________________________ City:____________________________ State: ______ Postal Code: ______

Note: The City of Pittsburgh’s standard payment terms are Net 45

By signing below the vendor acknowledges that the City of Pittsburgh accepts no responsibility for goods, equipment or services delivered without a formal written Purchase Order and/or Change Order.

Signature of Corporate Officer Title

Printed Name Date

If Yes, How Much?