MAYOR LINDA GORTON
WILLIAM O’MARA
COMMISSIONER
FINANCE
200 East Main St., Lexington, KY 40507 / 859.425.2255 Phone / 859.258.3385 Fax / lexingtonky.gov
Your business has recently been set up as a vendor in the Lexington-Fayette Urban County Government’s financial
system. Please provide us with the following information so that we can ensure our records are complete and that you
receive purchase orders and payments correctly and in a timely manner.
Please complete this form and attach a copy of your W-9 and return to: LFUCG - Division of Central Purchasing,
200 E. Main St., Room 338, Lexington, KY 40507 or fax to 859.258.3322.
Business Name_____________________________________ CERTIFICATIONS
Phone Number ( )_______________________________
Ky MWBE Certification from KTC ___
Fax Number ( )_________________________________
SBA (8)a Certification ___
E-Mail Address_____________________________________
WBE Certification from WBENC or NWBOC ___
Tax ID Number___________________________________
MBE Certification from TSMSDC ___
Name of person completing form_______________________
Section 3 Certified Business (HUD) ___
MIN
ORITY AND/OR WOMAN OWNED BUSINESS
INFORMATION: (Please check all that apply)
African-American Business Enterprise ___
Asian Indian-American Business Enterprise ___
Asian Pacific-American Business Enterprise ___
___
___
___
___
Hassidic Jew-American Business Enterprise
Hispanic-American Business Enterprise
Native-American Business Enterprise
Woman-Owned Business Enterprise
NONE ___
Other__________________________________
REMITTANCE ADDRESS
Address_______________________________________
City___________________________________________
State ____________________Zip Code_______________
ORDERING ADDRESS
Address ________________________________________
City ___________________________________________
State_____________________ Zip Code______________
