Fillable PURCHASING SERVICES * 801 Leroy Place * Socorro, (New Mexico Institute of Mining & Technology)

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PURCHASING SERVICES * 801 Leroy Place * Socorro, (New Mexico Institute of Mining & Technology)

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PURCHASING SERVICES * 801 Leroy Place * Socorro, NM 87801 * 575-835-5886 * Fax 575-835-5887 * purchasing@nmt.edu
TAXPAYER IDENTIFICATION REQUEST and SUBSTITUTE W-9
NMT REQUIRES THIS FORM BE COMPLETED IN FULL. INCOMPLETE FORMS OR REGULAR W-9 FORM WILL NOT BE PROCESSED
FOREIGN VENDORS SHOULD COMPLETE THIS FORM AND ATTACH THE APPROPRIATE W-8
FEDERAL LAW REQUIRES NMT TO OBTAIN THE INFORMATION REQUESTED WHEN MAKING A REPORTABLE PAYMENT TO A VENDOR. FAILURE TO PROVIDE COMPLETE INFORMATION AS REQUIRED BY THE IRS MAY
RESULT IN THE VENDOR'S PAYMENT SUBJECT TO 28% FEDERAL INCOME TAX BACKUP WITHHOLDING. THE VENDOR MAY ALSO BE SUBJECT TO A $50 PENALTY IMPOSED BY THE IRS UNDER SECTION 6723.
LEGAL NAME : _______________________________________________________________________________________________
BUSINESS NAME: _______________________________________________________________________________________________
(if different from above)
ORDERING ADDRESS: ______________________________________________________________________________________________
______________________________________________________________________________________________
CITY: _______________________________ STATE: ____________ COUNTRY: _________________________
TELEPHONE NUMBER: ________________________________________ INTERNET ADDRESS: _________________________________________________
FAX NUMBER: _________________________________________ EMAIL ADDRESS: _________________________________________________
REMIT TO ADDRESS (if different from ordering address):
CITY: ____________________________ STATE: ______________ COUNTRY: _______________________
ZIP/Postal
Code:__________________________
DUNS: _____________________________________________________________ COMPANY TIN / EIN: __________________________________________
SOLE PROPRIETOR __________________________________________
BUSINESS TYPE – Please check Business Type - Required
( ) C CORPORATION (CP) ( ) FOREIGN GOVERNMENT (FG)
( ) S CORPORATION (SC) ( ) FOREIGN SUPPLIER (FS)
( ) PARTNERSHIP (PT) ( ) FOREIGN PERFORMED CONTRACT (FP)
( ) TRUST / ESTATE (TE) ( ) NOT FOR PROFIT ORGANIZATION (NP)
( ) LLC-LIMITED COMPANY (LL) - ( ) Partnership ( ) C Corporation ( ) S Corporation ( ) FEDERAL OR STATE GOVERNMENT AGENCY (GV)
( ) INDIVIDUAL (IN) – Please complete the attached Independent Contractor Determination Form on Page 2
( ) SOLE PROPRIETOR / SINGLE MEMBER LLC (SP) – Please complete the attached Independent Contractor Determination Form on Page 2
___________________________________________________________________________________________________________________________
OWNERSHIP AND / OR SBA CATEGORY – Required
( ) SMALL BUSINESS (SM) ( ) LARGE BUSINESS (BB) ( ) 8(a) CERTIFIED* (8A)
( ) SMALL DISADVANTAGED BUSINESS* (SD) ( ) LARGE DISADVANTAGED BUSINESS* (LD) ( ) HUBZONE SMALL BUS.* (HS)
( ) WOMEN OWNED SMALL DISADVANTAGED* (WS) ( ) WOMEN OWNED LARGE BUSINESS* (WL) ( ) EDUCATIONAL INSTITUTION (EI)
( ) VETERAN OWNED SMALL BUSINESS* (VS) ( ) NATIVE AMERICAN / INDIAN OWNED* (NA) ( ) MINORITY OWNED* (NM)
( ) HISTORICALLY BLACK COLLEGE* (BM) ( ) WOMEN OWNED SMALL BUSINESS (WB) ( ) FOREIGN PARTNERSHIP (PF)
*NOTE: please attach copies of your certification for this category of business from the SBA or other certifying authority. This certification is valid for one year. If your status changes, it is your responsibility to
notify NMT. Definitions of Small Business Owned and Small Disadvantaged Business definitions are available on the NMT website: https://www.nmt.edu/purchasing-services-forms
Individual / Sole Proprietor: Are you a Citizen of the United States? Yes ____ No ____ If no, what Country? _______________________
Indicate Visa type and attach the following completed forms and documents when applicable:
____ Permanent Resident Alien (individual) – Attach copy of Green Card
____ Non-Resident Alien (individual or company) – Attach copy of Visa, Passport and IRS Form W-8BEN
____ Federal Form 8233 Exemption from withholding on compensation for Independent Personal Services of a Non-Resident Alien Individual
Page 1 of 2 04/16
Zip/Postal
Code:
_______________________
SSN IF INDIVIDUAL;
______________________________________________________
CONFLICT OF INTEREST - Required
1. Are you an employee of NMT? Yes _______ No _______
2. Is any immediate family member employed by NMT or any of its entities? Yes _______ No _______
If Yes, list name and NMT Department: ________________________________
Relationship: ________________________________
3. To the best of your knowledge, are any officers, directors, trustees, partners, or an Yes _______ No _______
individual holding any position in management of this business, a member of the NMT Board of
Regents, an immediate family member of the NMT Board of Regents, or an employee of NMT or any of its entities? If “yes” attach details.
I acknowledge that NMT policy calls for issuance of an official NMT Purchase Order signed by an authorized individual for all purchases except those accomplished with a NMT
Procurement Card prior to a purchase being made. Failure to obtain an NMT Purchase Order prior to supplying goods or services may result in either delay of payment or non-
payment.
Further, I a
cknowledge that information obtained in this questionnaire will be used to establish/update NMT’s database and that these changes may affect information in related
databases such as student records or employee information.
UNDER 15 U.S.C. 645(d), ANY PERSON WHO MISREPRESENTS ITS SIZE STATUS SHALL (1) BE PUNISHED BY A FINE, IMPRISONMENT, OR BOTH; (2) BE SUBJECT TO ADMINISTRATIVE
REMEDIES; AND (3) BE INELIGIBLE FOR PARTICIPATION PROGRAMS CONDUCTED UNDER THE AUTHORITY OF THE SMALL BUSINESS ACT.
* CERTIFICAT
ION: Under penalties of perjury, the individual signing this form below, certifies that:
1. The payee’s taxpayer identification number (TIN) is correct,
2. The payee is not subject to backup withholding due to failure to report interest and dividend income,
3.
The payee is a U.S. person, and (Does not apply to Foreign Vendors)
4. T
he payee is exempt from Foreign Account Tax Compliance Act (FATCA) reporting. Please provide your Exempt Payee code (if any) ____________
Please provide your Exemption from FATCA reporting code (if any) ___________
Please consult www.irs.gov
if you have questions
New Mexico Tech
TIN: 85-6000-411 * New Mexico Tech DUNS: 04-135-8904
INDEPENDENT CONTRACTOR DETERMINATION (to be completed by Individual or Sole Proprietors) If “yes” is checked, please explain.
1. Will NMT determine when, where, or how the work is to be performed? Yes _______ No _______
2. Will NMT provide any training to the contractor or its employees? Yes _______ No _______
3. Are the services proposed in this contract currently being performed on the NMT Campus? Yes _______ No _______
4. Will any current NMT employees be involved in performing any of the proposed services of this contract? Yes _______ No _______
5. Are the services proposed in this contract a continuation of work from a current or prior contract? Yes _______ No _______
6. Will the proposed services be performed on NMT property? Yes _______ No _______
7. Will any NMT owned property or equipment be used in the performance of the proposed services? Yes _______ No _______
8. Is the contractor allowed to provide the proposed services without a business license/registration? Yes _______ No _______
9. Please describe the services that you will be providing to NMT.
Explanation/ description: ________________________________________________________________________________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
COMPANY / INDIVIDUAL REPRESENTATIVE
_____________________________________________________________________________________________________________________
Print or Type Name and Title of Individual Completing Form
______________________________________________________________________ ____________________________________
* Signature Date
To be completed by NMT Banner Number assigned ________________________________
IRS checked on _______________ by ___________ #_________
Vendor Codes____________________________________
Page 2 of 2
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
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PURCHASING SERVICES * 801 Leroy Place * Socorro, (New Mexico Institute of Mining & Technology)

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Completed 8 February 2022

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