Vendor Profile FOrm by 97HsPX2D

VIEWS: 11 PAGES: 2

									   If returning to Accounts Payable-
   FAX to: (912) 478-0665
   If returning to Procurement-
   FAX to: (912) 478-0463 or by
   email:
   purchasing@georgiasouthern.edu

   ATTN:

Vendor Name: __________________________________________                           Individual/Sole Prop.
(As shown on your Income Tax Return)                                                 C Corporation
                                                                                     S Corporation
Business Name __________________________________________                          Partnership
(If different from Above)                                                        Limited Liability Co.
                   Taxpayer Identification Number                                    Non-resident Alien
                                                                                     Other___________
Employer Identification Number:              Social Security Number:
                                                                                     Exempt From
                                      OR
                                                                                     Backup Withholding
__ __ - __ __ __ __ __ __ __                 __ __ __ - __ __ - __ __ __ __

REMIT TO :                                                  SALES & ORDERING:

Address Line 1:______________________                       Address Line 1:______________________
Address Line 2:______________________                       Address Line 2: ______________________
City/State/Zip: ______________________                      City/State/Zip: _______________________
                                                            (Actual Physical Address – Not a P.O. Box)
Phone: (   ) _______________ Ext._____                      Phone: ( ) _______________ Ext. _____
Fax: (     ) __________________                             Fax: ( ) _________________
Contact Name: ______________________                        Contact Name: _______________________
Email: ______________________________                       Email:_____________________________
Payment Terms: ______________________                       Internet Address:______________________
OWNERSHIP                                                 If business is minority-owned, please
Is the business a minority-owned business?                specify one ethnic background:
         YES            NO                                    African American     Asian American
Is the business a small business?                             Native American       Pacific Islander
         YES            NO                                    Hispanic
    <100 employees OR < $1M gross receipts


Commodities (Please indicate the type of products sold/manufactured): _________________________

                                                     Page 1 of 2
         Individuals or Businesses may receive a form 1099 depending
         on payment type and IRS regulations

CERTIFICATION
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 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 (defined in the instructions).

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 of
underreporting interest or dividends on your tax return. For real estate transactions, item 2 does
not apply. For mortgage interest paid, the 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.”

____________________________________________________________________________



____________________________________ Date _________ Telephone (                   ) ___________
          Signed

__________________________________________________
          Printed Name & Title




Rev. 02/22/2012
                                                     Page 2 of 2

								
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