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Supplier Data FormSheet3 Sheet2 Sheet1 SUPPLIER NAME: SUPPLIER ADDRESS FOR PURCHASE ORDERS: CONTACT EMAIL: ADDITIONAL CONTACT NAME: CONTACT NAME: ADDITIONAL CONTACT PHONE NUMBER: CONTACT PHONE NUMBER: CONTACT FAX NUMBER: ADDITIONAL CONTACT FAX NUMBER: ADDITIONAL CONTACT EMAIL: SUPPLIER ADDRESS FOR PAYMENT (REMIT TO): CITY, STATE, ZIP ADDRESS LINE 1 ADDRESS LINE 2 PREFERRED PAYMENT METHOD: TAXPAYER ID #: DUNS NUMBER: 1099 REPORTABLE?: INCOME TAX TYPE: MINORITY STATUS MBE: MBE TYPE: WBE: CERTIFYING AGENCY, IF KNOWN: CERTIFICATE EXPIRATION DATE, IF KNOWN: REQUESTOR: ADDITIONAL INFORMATION OR COMMENTS: CHECK ELECTRONIC MISC1 - RENT MISC3 - OTHER INCOME MISC6 - MEDICAL & HEALTH CARE PAYMENTS MISC7 - NON-EMPLOYEE COMPENSATION MISC14 - GROSS PROCEEDS PAID TO AN ATTORNEY ü AFRICAN AMERICAN ASIAN AMERICAN HISPANIC AMERICAN NO YES SUPPLIER MANUFACTURER SUPPLIER TYPE: DEVELOPER CONSULTANT EMPLOYEE CONTRACTOR CAPITAL CONSTRUCTION EMPLOYEE #: PREFERRED COMMUNICATION METHOD FOR PURCHASE ORDERS: FOR PURCHASING USE ONLY: DATE SUPPLIER CREATED: SUPPLIER #: CREATED BY: FAX - # EMAIL: REQUESTOR PHONE #: RETURN THIS FORM TO: SUPPLIERS@STLMSD.COM SUPPLIER DATA FORM LIST PRODUCT AND SERVICES CODES AS APPLIES BELOW: 2Complete this form and submit to Purchasing