3 | Revised 11/2/12
Payables Office
Dept. 3314
1000 E University Avenue
Laramie WY 82071
307-766-5296
FAX: 307-766-6762
Procurement Services
Dept. 3605
1000 E University Avenue
Laramie WY 82071
307-766-5233
FAX: 307-766-2800
Vendor Form/Substitute W-9
Instructions: If you are a U.S. citizen, resident alien or U.S. business, please provide all information as requested in the spaces provided. If you, the recipient, or
the beneficiary of the payment is not a U.S. citizen, resident alien or U.S. business please provide all information as requested, but DO NOT sign the
certification in Section B and contact the Tax Office at 307-766-2821 to complete the additional required tax forms. Please print or complete the fillable Vendor
Form at http://www.uwyo.edu/procurement/vendor-application-form/
Section A - All Vendors Must Complete
General Information
Company, Business or Individual Name: _________________________________________________________________________________________
Order Address: _______________________________________________ City:_______________________ State: ______Zip:____________
Order E-Mail Address: ____________________________________________________Order Fax #:_______________________________________
Bid Solicitation Address: _______________________________________________ City:_______________________ State: ______Zip:____________
Bid E-Mail Address: ____________________________________________________ Bid Fax #:________________________________________
Remittance Address: _______________________________________________ City:_______________________ State: ______Zip:____________
Sales Contact: ________________________________________ Phone #:____________________Email____________________________
Management Contact: ________________________________________ Phone #:____________________Email____________________________
Toll Free Phone Number: ________________________________________ WWW Address: ______________________________________________
ALL COMPANIES PRODUCING PRODUCTS BEARING THE UNIVERSITY’S MARKS MUST RECEIVE PRIOR APPROVAL THROUGH THE UNIVERSITY’S LICENSING OFFICE
Section B – Substitute W-9: Request for Taxpayer Identification Number and Certification – All Vendors
Must Complete.
Check Federal Tax Classification
Individual/sole proprietor C Corporation S Corporation Partnership Trust/Estate
Limited Liability Company Enter the tax classification (C= Corporation, S= S Corporation, P=Partnership) ___
Government agency or organization that is tax-exempt under IRS guidelines
Foreign Individual Foreign Business Other___________________
Check as many as apply: Medical Service Provider Lawyer/Attorney Agent
Required: 1099 Address, if different_________________________________________________________________________________________
Taxpayer Identification Number
Employer Identification Number (EIN) _ _ - _ _ _ _ _ _ _ -or- Social Security Number _ _ _ - _ _ - _ _ _ _
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that
I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup
withholding, and
3. I am a U.S. citizen or other U.S. person.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you
have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or
abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and
dividends, you are not required to sign the certification, but you must provide your correct TIN.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Signature______________________________________________________Date___________________
