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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
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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