PITT COMMUNITY COLLEGE
VENDOR INFORMATION FORM
Please return completed form to:
Pitt Community College
Attn: Sandy Richardson srichardson@email.pittcc.edu
Purchasing Department
PO Drawer 7007 - Greenville, NC 27835-7007
Phone (252) 493-7279, Fax (252) 321-4214
___________________________________________________________________
___________________________________________________________________
Pitt CC Employee Contact:
Official Nam
e:
(
$
s
reported on your tax
return
)
Official Business Address:
Remittance Business
Name
(
If different from above)
Remittance Address
___________________________________________
____________________________________________________________________
Home/Business Telephone: _____________________
Fax Number: _____________
_
_
_
_____
Authorized Signature: ____________________________________________________________________
Print Name: __________________________________________________________________________________
Title: ________________________________________________________
Date:_________________________
Please check all that apply:
1099 Vendor
Asian American Owned
American Indian
Black Owned
Disabled Business Enterprise
Disabled Owned
Government Agency
Hispanic Owned
Non-profit Work Center for Blind & Severely Dis
abled
Socially
and Economically
D
isadvantaged
Women
O
wned
Mobile Number: _________________
Are the terms f
or payment
Net
30
Days?
Yes
No
If no, please explain: ________________________________________________________________________
No
E-Mail Address: __________________________________________
Are you currently an employee of Pitt Community College?
Yes
If no, have you ever been a Pitt Community College employee?
Yes
No
If yes, what was the last year paid by Pitt Community College? ___________________________________
Is anyone in your immediate family employed at Pitt Community College?
Yes
No
___________________________________________
___________________________________________
___________________________________________
Revised 9/24/18
