VENDOR REGISTRATION FORM

Fill in the information below. Click the "Create form" button Print and sign the created form. Fax form to UCA Purchasing

Vendor Business Contact	Contact Phone	/ / Date
Legal Business Name	Business Street Address
City	State	Zip
Country	Business Phone	Foreign Zip Code
Fax Number	Toll Free Number
Company Web Address
E-mail Address (if none, enter N/A)
SECTION "A" VENDOR MAILING ADDRESS (Please complete if different from business address)
Address		City
State	Zip	Foreign Zip
SECTION "B" VENDOR SHIPPING ADDRESS (Please complete if different from business address)
Address		City
State	Zip	Foreign Zip
SECTION "C" VENDOR REMITTANCE ADDRESS (Required to be completed)
Address		City
State	Zip	Foreign Zip
Accounts Receivable Contact Name	Phone Number	Fax number
SECTION "D" BUSINESS CLASSIFICATION (SELECT ALL THAT APPLY)
American Indian (AI)	Asian (AS)	Attorney (AT)
Black American (BL)	Corporation (CO)	Company (CP)
Employee Owned (EM)	Foreign (FO)	Hispanic American (HS)
Incorporated (IC)	Individual (IN)	Limited Liability Corporation
Limited Partnership (LP)	Medical (MD)	Minority Owned (MN)
Nonprofit (NP)	Partnership (PA)	Pacific Islander (PI)
State Agency (SA)	Sole Proprietor (SP)
SECTION "E" TAX STATUS (Choose one status and complete the associated boxes) Form W-9       Taxpayer Identification Number Request Please complete the following information. We are required by law to obtain this information from you when making a reportable payment to you. If you do not provide us with this information, your payments may be subject to a 28% federal income tax backup withholding. Also if you do not provide us with this information, you may be subject to a $50 penalty imposed by the Internal Revenue Service under section 6723. Use this W-9 form only if you are a U.S. person or business (including U.S. resident alien). If you are a foreign person, use the appropriate Form W-8. Individual/Sole Proprietor: A sole proprietorship may have a trade name (doing business as), but the legal name is the name of the business owner.
Business or Trade Name
Federal Identification Number (or Social Security Number if SP or IN)
Partnership: A Partnership may have a trade name (doing business as), but the legal name is the list of the names of the partners.
Name of Partnership
Partnership's Employer Identification Number
Partnership's Legal Name (Name of First Partner)
Limited Liability Corporation: (LLC)
Name of LLC
Federal Identification Number
Corporation, exempt charity, or other entity A corporation may use an abbreviated name, but the legal name is the name on the articles of incorporation.
Name of Corporation or Entity
Federal Identification Number
Are you exempt from Form 1099 reporting? Yes    No   You must answer Yes or No. If you are exempt from Form 1099 reporting, please choose one: Corporation Tax Exempt Charity under 501 (a) or IRA The United States of any of its agencies or instrumentalities A state, the District of Columbia, a possession of the United States, or any of their political subdivisions
SECTION "F" CERTIFICATION
Vendor certifies under penalty of perjury that The registration information provided herein is current, complete and correct The Tax Identification Number provided is correct, that payee is not subject to backup withholding due to failure to report interest and dividend income and that I am a U.S. person or business (including a U.S. resident alien). Note: the Internal Revenue Service does not require consent to any provisions of this document other than the certification required to avoid backup withholding. Signature:_______________________________________          Date: _____________________

For the following chart, please reference the "BANNER COMMODITY CODES" link found on our web site http://www.uca.edu/divisions/admin/purchasing to list all goods/services pertinent to your organization. In some instances, this chart may NOT apply to you or your organization. If this is the case, please skip this chart and complete the section below. COMMODITY CODE LISTING:
Class (3-digit)	Sub-Classes 1 (5-digit)	2	3	4	5	6
BRAND NAMES:

Signature name

Title