Submit completed, signed Supplier Information Form to-
Email scan: customercareteam-pds@case.edu Procurement Policy: http://www.case.edu/bizpolicies/
Fax: Customer Care Team 216-368-5088
Mail: Customer Care Team
10620 Cedar Avenue
Cleveland, OH 44106-4909
Supplier Information Form
W9 Certification of Supplier Information
The IRS requires that you provide information which allows us to complete 1099 reporting. W9 Certification: Under penalties of perjury, I certify that the number shown on this form is my correct
Your payments may be subject to backup withholding if you fail to provide a correct Taxpayer Taxpayer Identification Number, and I am not subject to backup withholding as a result of a failure to
Identification Number (TIN). report all interest or dividend income, and I am a US citizen or US person.
Note: US Persons filling out this form do NOT have to fill out a W-9, non US Persons must
fill out a W-8BEN in addition to this form.
*Please enter your TIN (SSN or EIN) below
______________________________________ *Sign Here
____________________________________________ *Date _____________________
In order to receive payment from Case, the recipient must be added to PeopleSoft as a vendor. All fields marked * are mandatory on the Supplier Information Form. Incomplete submission cannot be processed and will
be returned for completion. For businesses: Must be completed and signed by a designated company representative.
Supplier Information
_________________________________________________ ______________________________________________________
*Name of Company or Individual DBA (Doing Business As), if applicable
*Supplier Type Business Type
Individual Partnership □ Contractor □ Retailer
Sole Proprietor Non-Profit Organization □ Distributor □ Broker
Corporation Government Entity □ Manufacturer □ Other (please specify)
_______________
Limited Liability Company Exempt Payee Business Size Small Business Concern Large Business Concern
________________________
*Please Check One Add as a new vendor to PeopleSoft □ Update existing entry (ID or Short Name) _____________________________
Supplier Diversity Information
Check all that apply (Please attach copy of SBA certification)
□ Small Business Enterprise (SBE) □ Minority-Owned Business (MBE)
□ Disadvantaged Business Enterprise (DBE) HUB Zone - Historically Underutilized Business Zones
□ Disabled Veteran Business Enterprise (DVBE) HBCU / MI
□ Women-Owned Business Enterprise (WBE) Other (please specify)
________________________________
Supplier Business Addresses & Payment Information
*Remit to AddressPayment will be mailed here
_________________________________________________________________________________________________________
*Address (Number, Street, and Apt or Ste number)
_______________________________________ ___________________________________ _____________________________
*City *State *Zip Code
_______________________________________ ___________________________________ _____________________________
*Email Address *Phone Number Fax Number
________________________
Supplier’s Address (if different than address above) or Previous Address (if updating existing PeopleSoft entry)
_________________________________________________________________________________________________________
Address (Number, Street, and Apt or Ste number)
_______________________________________ ___________________________________ _____________________________
City State Zip Code
________________________
Businesses, Do You Accept Credit Card Payments? Yes No Ecommerce / PeopleSoft? Yes No
Supplier Contact at Case Western Reserve University
______________________________________ ___________________________________________ ________________________________
*Case Contact Name *Contact Email *Contact Phone
__________________________________ _____________________________________________________________________
*Contact Department *Contact Signature
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