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 purchasing@jsums.edu.
To be processed, a direct deposit form must accompany this form.
Vendor Name
Sole Proprietor LLC Corporation
Other (Specify)Non-ProfitPartnership
Type of Business
Order Address Payment Address
Address
Address
City ZipST ZipSTCity
Contact Person:
Phone Number
Website:
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.
NoYes
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?
Name Date
Signature Title
Tax ID #/SSN
Purchasing Date
Fax Number
Certified
use separate sheet if needed
NoYes
Woman BE Small BE Disadvantaged BE
Minority BE
Certifying Agency
Email Address
Commodity/Service Provivided
