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Ventura Vendor Registration Form

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Ventura Vendor Registration Form Powered By Docstoc
					                      VENDOR REGISTRATION APPLICATION
                                         Rev: Mar 2012
                        For placement on Vendor Reference List


1. Business Name: ______________________________________________________________

2. DBA: (Doing Business As) ______________________________________________________

3. Remit Name: _________________________________________________________________

                                     If Vendor is an individual:
   Last Name: _____________________________ First Name: ___________________________
   Also Known As (AKA) Name: ___________________________________________________


4. Fed Tax ID Number: ___________________________________________________________

5. SSN # (if individual) : ___________________________________________________________

6. Physical Address of Business:
   Street: ___________________________ City____________________State_____Zip ________

   Mailing Address of Business:
   Street: ___________________________ City____________________State_____Zip ________

   Remittance Address of Business:
   Street: ___________________________ City____________________State_____Zip ________

7. Contact Persons:
   Person to whom quotation/bid requests should be mailed:
   Last Name: _______________________ First: ____________________ Phone:_____________
   Email Address: ________________________________________________________________
   Person to whom payment should be mailed:
   Last Name: _______________________ First: ____________________ Phone:_____________
   Email Address: ________________________________________________________________

8. Company FAX #: ______________________________________________________________

9. Company Website: ____________________________________________________________

10. Can your firm accommodate e-commerce?                Yes       No

11. Is your firm willing to support the City in an emergency and be registered as an
   Emergency Vendor?               Yes             No
12. It is mandatory that you list the specific NIGP Code that pertains to your company’s
     products and/or services.
       •   Please refer back to the NIGP Commodity Code link (Excel file), found on the Purchasing &
           Contracts Vendor Forms page in order to determine the appropriate code(s) for your
           company.
            ITEM #                            CLASS #                  Environmentally Certified
                                                                                   (Y/N)




If your business is within the city limits of the City of Ventura and/or you are providing services within
                     the City of Ventura, a City Business License will be required.

            If you currently have a City of Ventura Business License please enter it here.
                City Business License: ____________________________________

  All applications are subject to review and verification prior to placement on vendor reference list.
                      Visit the City of Ventura’s website at www.cityofventura.net

It is crucial to accompany this Vendor Registration with a W-9 & Supplemental Form in order
                               to be added to our registered list

    An appointment is necessary if you intend to meet with a Buyer. Please call (805)658-4719 for
                                           an appointment.

                 Please email this registration to: vendorregistration@cityofventura.net
                                                     or
                                                   mail to:
                             City of Ventura Purchasing & Contracts Division
                                          501 Poli St., Room 102
                                               PO Box 99
                                         Ventura, CA 93002-0099
                                         Living Wage Requirements
    (Applicable to contractors who work on non-Public Works service contracts, projects and programs, funded
                                        by the City of San Buenaventura)


Vendor understands and agrees that this Agreement is subject to the provisions of Chapter 2.525 of the San
Buenaventura Municipal Code, entitled “Living Wages and Benefits for City Services”, a copy of which has been
provided, or is available by request, to Vendor. By reason thereof, during the term of this Agreement, Vendor will
pay and/or provide the wages and/or benefits required therein to all of its employees engaged in whole or in part in
performing the services provided for by this Agreement. Moreover, Vendor will require any of it’s successors,
assigns and subcontractors who receive any compensation or other emoluments arising out the performance of the
services provided for by this Agreement to similarly pay and/or provide such wages and/or benefits to all of their
employees engaged in whole or in part in performing the such services. In addition, Vendor and any of its
successors, assignees and /or subcontractors, who received any compensation or other emoluments arising out of
the performance of the services provided for by this Agreement will post the “Notice to Employees” and provide the
other information required by Section 2.525.170 of Chapter 2.525 at the time in the manner provided for by that
section.

 Vendor also understands and agrees that any violation of Chapter 2.525 of the San Buenaventura Municipal Code
will be deemed to be a material breach of this Agreement entitling City to suspend or terminate this Agreement
and/or impose the civil penalties provided for by Section 2.525.400 of Chapter 2.525.

By initialing this Section, Vendor agrees that it has been provided with and read a copy of Chapter 2.525 of the San
Buenaventura Municipal Code as well as this Section, and that Vendor understands Chapter 2.525 and this
Section.

       Vendor’s initials: ______
  Form                                 W-9                                                Request for Taxpayer                                                                        Give Form to the
                                                                                                                                                                                      requester. Do not
  (Rev. January 2011)
  Department of the Treasury
                                                                                Identification Number and Certification                                                               send to the IRS.
  Internal Revenue Service
                                       Name (as shown on your income tax return)


                                       Business name/disregarded entity name, if different from above
See Specific Instructions on page 2.




                                       Check appropriate box for federal tax
                                       classification (required):    Individual/sole proprietor          C Corporation         S Corporation               Partnership       Trust/estate
           Print or type




                                                                                                                                                                                                Exempt payee
                                             Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶


                                            Other (see instructions) ▶
                                       Address (number, street, and apt. or suite no.)                                                            Requester’s name and address (optional)


                                       City, state, and ZIP code


                                       List account number(s) here (optional)


           Part I                                Taxpayer Identification Number (TIN)
  Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line                                                        Social security number
  to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
  resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other                                                                   –              –
  entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
  TIN on page 3.
  Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose                                                              Employer identification number
  number to enter.
                                                                                                                                                                         –

         Part II                                 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 (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 (defined below).
  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. See the
  instructions on page 4.
  Sign                                       Signature of
  Here                                       U.S. person ▶                                                                                     Date ▶

  General Instructions                                                                                                   Note. If a requester gives you a form other than Form W-9 to request
                                                                                                                         your TIN, you must use the requester’s form if it is substantially similar
  Section references are to the Internal Revenue Code unless otherwise                                                   to this Form W-9.
  noted.
                                                                                                                         Definition of a U.S. person. For federal tax purposes, you are
  Purpose of Form                                                                                                        considered a U.S. person if you are:
  A person who is required to file an information return with the IRS must                                               • An individual who is a U.S. citizen or U.S. resident alien,
  obtain your correct taxpayer identification number (TIN) to report, for                                                • A partnership, corporation, company, or association created or
  example, income paid to you, real estate transactions, mortgage interest                                               organized in the United States or under the laws of the United States,
  you paid, acquisition or abandonment of secured property, cancellation                                                 • An estate (other than a foreign estate), or
  of debt, or contributions you made to an IRA.
                                                                                                                         • A domestic trust (as defined in Regulations section 301.7701-7).
     Use Form W-9 only if you are a U.S. person (including a resident
  alien), to provide your correct TIN to the person requesting it (the                                                   Special rules for partnerships. Partnerships that conduct a trade or
  requester) and, when applicable, to:                                                                                   business in the United States are generally required to pay a withholding
                                                                                                                         tax on any foreign partners’ share of income from such business.
     1. Certify that the TIN you are giving is correct (or you are waiting for a                                         Further, in certain cases where a Form W-9 has not been received, a
  number to be issued),                                                                                                  partnership is required to presume that a partner is a foreign person,
     2. Certify that you are not subject to backup withholding, or                                                       and pay the withholding tax. Therefore, if you are a U.S. person that is a
     3. Claim exemption from backup withholding if you are a U.S. exempt                                                 partner in a partnership conducting a trade or business in the United
  payee. If applicable, you are also certifying that as a U.S. person, your                                              States, provide Form W-9 to the partnership to establish your U.S.
  allocable share of any partnership income from a U.S. trade or business                                                status and avoid withholding on your share of partnership income.
  is not subject to the withholding tax on foreign partners’ share of
  effectively connected income.

                                                                                                             Cat. No. 10231X                                                          Form W-9 (Rev. 1-2011)
                           SUPPLEMENTAL FORM FOR COMPLETING THE W-9

Request for Taxpayer Identification Number

Please complete the enclosed W-9 form and fill in the appropriate information below to assist us in complying with
the Internal Revenue Service’s regulations and State of California Independent Contractor reporting requirements.
Sole Proprietors must include their complete name, Social Security number and address by authority of the
California Revenue and Taxation Code Section 18646. Both the W-9 and the supplemental form must be
forwarded to the City.

Declaration by taxpayer:

   A form 1099 should be filed per IRS regulations for your organization because you are a(n):

       Individual/Sole Proprietor
       Attorney Corporation (Reference IRS Instructions for Form 1099-Misc, Box 14)
       Medical Corporation (Reference IRS Instructions for Form 1099-Misc, Box 6)
       Partnership
       Limited Liability Company
       Other:

   (Please note if you are an individual or sole proprietor, the California EDD requires that all employers of
   independent contractors also submit your legal name and social security number in addition to the
   company’s federal tax identification number. (Reference Senate Bill 542)

A form 1099 need not be filed because you are a (an) (check one):

       Corporation
       Payments were received for merchandise only. (Reference IRS Instructions for Form 1099-Misc,
       Exceptions)
       Non-Profit (Exempt Code)
       Other:


Company Name:

Print Name:

Signature:

Phone Number:

				
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