Vendor_Verification_Form.pdf

*Company Name: *City Issued Vendor Number:

*Date: *Federal Tax ID Number:

Accounting Contact Phone Number Email Address

Remittance Address Business Name (New W-9 Required) Federal Tax ID Number (New W-9 Required)

Address Website Authorized Individuals

Other:_____________________________________________________________________________

Only put the change information (Do not complete all sections)

Address City State Zip Code

Payment Remittance Address City State Zip Code

Billing Contact Phone Email

Name Title Phone Email

Name Title Phone Email

Website

Other

*Print Name

*Title *Date

Vendor Number: Date Process: initials:

City of Kingman Fiinance Signature: Date:

Vendor Verification Form

Please indicate the type of change needed:

Individual(s) authorized to contractually bind the company or firm (Please indicate if agent):

I attest the information provided on this form is true and correct. If requesting changes to my vendor profile, I authorize the City of Kingman to make the change indicated above on my account

*Officer's Signature

If you would like to make a change to any of the information we have on file for your company please complete Section 2 below. If you are not requesting any changes, please complete Section 3 and submit the signed form.

Required fields are indicated with a red * symbol

* Section 1:

Section 2 (Optional):

* Section 3:

Office Use Only