VENDOR REQUEST FORM
2017 Page 1 of 2 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.).
Period of Service (Permanency of the Relationship):
Start Date: / /
End Date: / / Other:
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?
Signature of Departmental Representative with Job Title Date
responsibility for service to be provided
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
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.
Human Resources Representative Date
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