VENDOR INFORMATION FORM
Issue Date: 03/16/2010, Revision 03/10/2017 (6)
In order to process payment to a vendor, the information on this form, in
conjunction with the Internal Revenue Service W-9 Request of Taxpayer Identification Number and Certification
(W-9) is
required. Please complete the fields below to request the creation of a new vendor record or to update the record of an existing
vendor. Completed forms can be faxed to 810-762-5645 or emailed to any staff member of the
Purchasing Department.
REQUIRED INFORMATION: CREATE New Record UPDATE Existing Record
____________________________________________________________________________________________________________
Business Name or Person Name
__________________________________________________ __________________________________________________
Website (if applicable)
Federal ID (EIN) or Social Security Number (SSN)
Have you ever done business with Mott Community College? Yes No
Have you ever done business under a different name? Yes No
____________________________________________________________________________________________________________
If yes, what name?
__________________________________________________ __________________________________________________
Sales Contact Name
Sales Contact Title
__________________________________________________ _______________________|__________________________
Sales Contact Email Address
Sales Contact Phone Number | Fax Number
Preferred method of receiving orders: Postal Mail Website Email Fax
Send purchase orders to:
__________________________________________________
Business Name or Person Name
__________________________________________________ __________________________________________________
Street Address
City, State, Zip
__________________________________________________ _______________________|__________________________
Email Address
Phone Number | Fax Number
Send payment to: __________________________________________________
Business Name or Person Name
__________________________________________________ __________________________________________________
Street Address
City, State, Zip
__________________________________________________ __________________________________________________
Attention (if applicable)
Billing Contact Name
__________________________________________________ _______________________|__________________________
Billing Contact Email Address
Billing Contact Phone Number | Fax Number
OPTIONAL INFORMATION:
If your business offers discounts to students who are enrolled in higher education courses, please provide the email
address and/or information on how students can access discounts (attach additional documents if necessary):
__________________________________________________________________________________________________
If your business has a scholarship program that students may apply to, please provide the email address and/or
information on how students can access the information and application (attach additional documents if necessary):
__________________________________________________________________________________________________
___________________________ F2 Purchasing Department
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