Fillable VENDOR REGISTRATION CITY OF WICHITA 455 N. MAIN; (City of Wichita)

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VENDOR REGISTRATION CITY OF WICHITA 455 N. MAIN; (City of Wichita)

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Country of origin: US
File type: PDF

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VENDOR REGISTRATION
CITY OF WICHITA
455 N. MAIN; 12TH FLOOR
Wichita, KS 67202
Phone: 316-268-4636 ● Fax: 316-268-4656 or 316-219-6308
FOR OFFICE
USE ONLY
VENDOR #
Company Name:
DBA name:
Mailing Address (for Purchase Orders)
Remittance Address (for Payment)
Street
Street
City
City
State
Zip
State
Zip
Phone
Phone
Fax
Fax
Preferred PO Delivery Method:
Paper (mail) Email to:_____________________
Preferred Payment Method:
Check Electronic Funds Transfer (ACH)
Sales Contact Person
Accounts Receivable Contact Person
Name & Title
Name & Title
Email Address
Email Address
Phone Number
Phone Number
TAX IDENTIFICATION NUMBER (TIN)
All USA firms that are established as an individual, self-employed or sole proprietorship must provide either their
Social Security Number (SSN) OR Federal Employer Identification Number (FEIN). All other businesses, such as
corporations, must provide their FEIN.
FEIN SSN
Are you a 1099 vendor?
(One MUST be selected.)
YES
NO
A completed IRS form W9 MUST be included with this
registration. Please initial to acknowledge ____________
Certification: Under penalties of perjury, I certify that:
1. The payee’s TIN is correct
2. The payee is not subject to backup withholding due to failure to report interest and dividend income, and
3. The payee is a U.S. Person
Signature of U.S. Person
Printed Name
Date
MINORITY OWNED BUSINESS
(A) Asian (AA) African American (AKA) Alaskan American (HI) Hispanic
(NA) Native American (PI) Pacific Islander (WO) Women Owned (VB) Veteran Owned
Vendor’s Signature Title Date
PLEASE RETURN FORM AND COMPLETED W9, EITHER BY MAIL OR FAX, TO THE ABOVE LISTED ADDRESS OR FAX
NUMBER. **REVISED 4/1/2019
If yes, please check the appropriate box:
Requested by:
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VENDOR REGISTRATION CITY OF WICHITA 455 N. MAIN; (City of Wichita)

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Completed 17 July 2020

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