FOR OPT USE ONLY: J#
Department of Purchasing and Travel
VENDOR REQUEST FORM
A completed form is required prior to adding your company/agency 's name to the Jackson State University's vendor database.
Please type or print legibly. You may fax the form to 601-979-0706 or scan and email the form to email@example.com.
To be processed, a direct deposit form must accompany this form.
Sole Proprietor LLC Corporation
Type of Business
Order Address Payment Address
City ZipST ZipSTCity
Business Profile (check all that apply)The information requested below is required and will be used for data collection purposes only.
Conflict of Interest Statement
Does any University employee serve as an officer, director or partner of this company?
If you answered "Yes" to any of the Conflict of Interest Statements,
Identify the individual(s) and their relationship to your company.
Does Jackson State University provide employment for any part (or member of the
party's immediate family) that has a 5% or greater ownership interest in this company?
Tax ID #/SSN
use separate sheet if needed
Woman BE Small BE Disadvantaged BE