Fillable Vendor Request Form (City)

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Vendor Request Form (City)

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The Vendor Request Form (City) form is 1 page long and contains:

  • 1 signature
  • 17 check-boxes
  • 29 other fields

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File type: PDF

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BROWSE CITY (AR) FORMS

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VENDOR REQUEST FORM
Last revised 2017 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
Vendor’s Name/Company:
Address:
Is this prospective vendor a current City of Little Rock
employee? Yes No
If yes, please attach approval from the City Manager.
Telephone:
SSN/Federal Employee ID Number/Individual Taxpayer ID Number:
Email Address:
Check appropriate box:
Individual/Sole Proprietor
C Corporation
S Corporation
Partnership
Limited Liability Company
Trust/Estate
Reimbursement
Non-Employee Travel
Other _________________
Minority Status (if applicable)
African American Owned
Women Owned
Other ____________________
Minority Certification Status (if applicable)
Certified
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.).
Period of Service (Permanency of the Relationship):
Start Date: / /
End Date: / / Other:
Payment Terms:
Will this prospective vendor provide a one-time service or will the
service be recurring and/or intermittent?
One-Time Service Recurring and/or Intermittent
Do you provide this service to anyone other than the City of Little Rock?
YES NO
DEPARTMENT INFORMATION
Department:
Division:
Signature of Departmental Representative with
responsibility for service to be provided
Job Title
Date
FINANCE DETERMINATION Vendor Class: Income Code:
This prospective vendor is approved to be set up as a vendor.
This service has been pre-determined to be treated as an independent contractor. (i.e. officials, umpires)
This prospective vendor should be evaluated further, this form will be forwarded to the Department of Human Resources
for final determination.
Reviewed by:
_________________________________________ _________________________________
Finance Representative Date
HUMAN RESOURCES DETERMINATION
This individual/sole proprietor is approved to set up as a vendor.
This individual/sole proprietor is NOT approved to set up as a vendor.
This prospective vendor should be evaluated further, please complete the Employee/Independent
Contractor Form and return to Human Resources.
Reviewed by:
_________________________________________ _________________________________
Human Resources Representative Date
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Vendor Request Form (City)

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Completed 19 July 2020

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