CITY OF DAHLONEGA
Finance Department
465 Riley Road
Dahlonega, GA 30533
Office (706) 864-6133
Fax (706) 864-4837
blee@dahlonega.gov
VENDOR REGISTRATION
(Please complete each line)
DATE: ___________________________
NAME OF VENDOR: ( Business Individual): ____________________________________________________________
SUPPLY VENDOR SERVICE VENDOR
DOES YOUR COMPANY HAVE EMPLOYEES: Yes No
IS YOUR COMPANY LICENSED TO DO BUSINESS IN GEORGIA: Yes No
BUSINESS INFORMATION:
CONTACT NAME: _____________________________________________________________________________
COMPLETE STREET ADDRESS: ___________________________________________________________________
CITY/STATE/ZIP: ______________________________________________________________________________
Complete Mailing Address (if different from above): __________________________________________
City/State/Zip: _________________________________________________________________________
E-MAIL: ____________________________________________________________ PHONE: _________________
CORPORATE WEBSITE: ________________________________________________ FAX:_____________________
NAME ON TAX RETURN (if different from vendor name above): ________________________________________
ORGANIZED AS: Individual Partnership Corporation Limited Liability Company Other
FEDERAL EIN -or- SOCIAL SECURITY #: ____________________________________________________________
SUMMARY OF PRODUCTS/ SERVICES PROVIDED TO THE CITY: _______________________________________________
__________________________________________________________________________________________________
DAHLONEGA BUSINESS LICENSE #_______EXPIRES_______LUMPKIN CO. BUSINESS LICENSE #_______EXPIRES_______
WHAT TYPE OF BUSINESS INSURANCE DO YOU CARRY? WHAT ARE THE MAXIMUM BENEFITS?____________________
NUMBER OF EMPLOYEES___________ NORMAL SELLING TERMS & DISCOUNTS OFFERED________________________
APPLICANT SIGNATURE: ____________________________________________________ DATE: ____________________
PRINTED NAME: _______________________________________________________ TITLE: _______________________
TO BE COMPLETED BY THE CITY OF DAHLONEGA
Are the following items included with this registration document?
W-9
Affidavit if service vendor with employees
Copy of Driver’s License if service vendor with no employees
Insurance Certificate VENDOR ID #: _______________________________________
