Vendor_Registration_Form.pdf.pdf

SDBE Program: Please select all applicable vendor characteristics:

Disadvantaged Business Enterprise Small Business - as defined by the U.S. Small Business Administration Women-Owned Business - % women owned / controlled % Minority-Owned Business - % Minority owned / controlled %

DUNS Number -

Ethnicity(ies)

If you checked any of the above boxes, please provide a brief description of your business:

If you checked any of the above boxes, do you wish to receive notifications of upcoming contract opportunities?

PURCHASE ORDER ADDRESS

BUSINESS NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP CODE

CONTACT PERSON

EMAIL ADDRESS

TELEPHONE NUMBER

Do you consent to receive Forms 1099 by email?

Do you wish to receive payments by electronic funds transfer?

PAYMENT REMITTANCE ADDRESS

BUSINESS NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP CODE

CONTACT PERSON

EMAIL ADDRESS

TELEPHONE NUMBER

Check here if same as PO address

The City of

HEATH, TEXAS

VENDOR REGISTRATION FORM

Updated 2023

Please print legibly or type this information. Form must be completed and signed by authorized individual.

If you are a single member LLC classified as a Disregarded Entity on your W-9, you MUST provide the owner’s SSN or EIN, not the LLC’s EIN (see IRS pub 3402).

NEW DOMESTIC VENDOR - Attach the most current IRS W-9 form, along with this form; both MUST be filled out in their entirety.

NEW FOREIGN ENTITY - Attach the most current, appropriate, IRS W-8 form, along with this form; both MUST be filled out in their entirety

Please provide the City Department or Employee you are working with:

City Department City Employee UPDATE EXISTING VENDOR - Attach the most current IRS W-9/W-8 form, along with this form; both MUST be filled out in their entirety.

Select all types of applicable update(s):

Address Name Tax ID Contact Information ACH/EFT Other:

Any vendor who accepts payment confirms the following: the invoice is true and correct; the work, service or materials as shown by the invoice or claim have been completed or supplied in accordance with the plans, specifications, orders or requests furnished the vendor; and the vendor has made no payment, directly or indirectly, to any elected official, officer or employee of this City, of money or any other thing of value to obtain payment.

I certify that the information supplied herein is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principal or officer is now debarred or otherwise declared ineligible by a public agency for bidding or furnishing materials, supplies or services, to any other public agency thereof.

Signature of Person Authorized to Sign Date Signed

Print Name Title

Return to Procurement Services:

vendorregistration@heathtx.com 200 Laurence Drive Heath, Texas 75032 Ph (972) 771-6228 Fax (972) 961-4932

(Internal use only) Incode Vendor ID: Entered by:

Helpdesk Ticket #: Date:

mailto:vendorregistration@heathtx.com