* PAGE 1 OF 2 *
* PURCHASING WILL PROCESS NEW VENDOR REQUESTS WHEN BOTH FORMS ARE RECEIVED.
Send completed form & W-9 to Purchasing Department, email to purchasing@icc.edu
VENDOR APPLICATION FORM
NOTICE: *COMPLETED W-9 MUST BE SUBMITTED WITH EVERY NEW VENDOR REQUEST.
STEP 1 TAX INFORMATION
VENDOR NAME (if sole proprietor, please list name of owner and name of business):
ORDER ADDRESS:
REMITTANCE NAME (if different than vendor name listed above):
REMITTING ADDRESS (if different than order address listed above):
SALES CONTACT:
PHONE NUMBER:
FAX:
FEDERAL TAX CLASSIFICATION (select one):
INDIVIDUAL/SOLE PROPRIETOR
CORPORATION
TAX INDENTIFICATION NUMBER (TIN from Part I on W-9):
SSN:
or
FEIN: __________________________________
PURCHASE INFORMATION:
SERVICES, CONSULTANTS
GOODS/PRODUCTS (i.e. Supplies, Printing, Dues, Publications, Software, Advertising).
* PAGE 2 OF 2 *
* PURCHASING WILL PROCESS NEW VENDOR REQUESTS WHEN BOTH FORMS ARE RECEIVED.
Send completed form & W-9 to Purchasing Department, email to purchasing@icc.edu
STEP 2 TYPE OF OPERATION (OPTIONAL, CHECK ALL THAT APPLY)
MINORITY OWNED BUSINESS means a business which is at least 51 percent owned by one or more
minority persons, or in the case of a corporation, at least 51 percent of the stock in which is owned by one or
more minority persons; and the management and daily business operations of which are controlled by one
or more of the minority individuals who own it.
UNDER THIS DEFINITION, THIS FIRM IS (check where appropriate):
A MINORITY OWNED BUSINESS
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
HISPANIC OR LATINO
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
CHECK HERE IF YOU HAVE BEEN CERTIFIED BY THE MINORITY AND FEMALE BUSINESS
ENTERPRISE DIVISION OF THE ILLINOIS DEPARTMENT OF CENTRAL MANAGEMENT SERVICES.
OTHER CERTIFYING ORGANIZATION: _____________________________________________
MINORITY OWNED BUT NOT CERTIFIED
NOT APPLICABLE
FEMALE OWNED BUSINESS means a business which is at least 51 percent owned by one or more
females, or, in the case of a corporation, at least 51 percent of the stock in which is owned by one or more
females; and the management and daily business operations of which are controlled by one or more of the
females who own it.
UNDER THIS DEFINITION, THIS FIRM IS (check where appropriate):
FEMALE OWNED BUSINESS
CHECK HERE IF YOU HAVE BEEN CERTIFIED BY THE MINORITY AND FEMALE BUSINESS
ENTERPRISE DIVISION OF THE ILLINOIS DEPARTMENT OF CENTRAL MANAGEMENT SERVICES.
OTHER CERTIFYING ORGANIZATION: _____________________________________________________
FEMALE OWNED BUT NOT CERTIFIED
NOT APPLICABLE
BUSINESS OWNED BY A PERSON WITH A DISABILITY means a business that is at least 51 percent
owned by one or more persons with a disability and the management and daily business operations of which
are controlled by one or more of the persons with disabilities who own it. A not-for-profit agency for persons
with disabilities that is exempt from taxation under Section 501 of the Internal Revenue Code of 1986 is also
considered a business owned by a person with a disability.
UNDER THIS DEFINITION, THIS FIRM IS (check where appropriate):
BUSINESS OWNED BY A PERSON WITH A DISABILITY
CHECK HERE IF YOU HAVE BEEN CERTIFIED BY THE MINORITY AND FEMALE BUSINESS
ENTERPRISE DIVISION OF THE ILLINOIS DEPARTMENT OF CENTRAL MANAGEMENT SERVICES.
OTHER CERTIFYING ORGANIZATION:
BUSINESS OWNED BY A PERSON WITH A DISABILITY BUT NOT CERTIFIED
NOT APPLICABLE
OTHER (Check where appropriate):
VETERAN OWNED SMALL BUSINESS
CERTIFYING ORGANIZATION: ____________________________________________________
SERVICE-DISABLED VETERAN OWNED SMALL BUSINESS
CERTIFYING ORGANIZATION: _____________________________________________________________
OTHER: ____________________________________________________________________________________
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