VENDOR REQUEST FORM
May 2014 Page 1 of 1 HR/Vendor Request Form
This form is to be completed by the requesting department. This form should accompany all W-9 forms that are
submitted to the Department of Finance (Purchasing).
PROSPECTIVE VENDOR INFORMATION
Is this prospective vendor a current City of Little Rock
employee? Yes No
If yes, please attach approval from the City Manager.
SSN/Federal Employee ID Number/Individual Taxpayer ID Number:
Check appropriate box:
Limited Liability Company
Minority Status (if applicable)
African American Owned
Minority Certification Status (if applicable)
Certifying Entity __________________________
Certification Number ______________________
Briefly describe the nature of the service to be provided or provide the reason or explanation the individual
should be set up as vendor (i.e. reimbursement, non-employee travel, etc.).
Start Date: / /
End Date: / / Other:
Will this prospective vendor provide a one-time service
or will the service be recurring and/or intermittent?
Recurring and/or Intermittent
Signature of Departmental Representative with Job Title Date
responsibility for service to be provided
FINANCE DETERMINATION Vendor Class: Income Code:
This prospective vendor is not an individual and/or sole proprietor and is approved to be set up as a vendor.
This prospective vendor should be evaluated further, this form will be forwarded to the Department of
Human Resources for final determination.
Finance Representative Date
HUMAN RESOURCES DETERMINATION
This individual/sole proprietor is approved to set up as a vendor.
This prospective vendor should be evaluated further, please complete the Employee/Independent
Contractor Form. Return to Human Resources.
Human Resources Representative Date
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