Request Company Accounts Receivable Contact Information Form - Excel by ndb36858

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									          Yale University                                                                                                                                            Vendor Setup Request
          Fax completed form to 432-3061, or e-mail from authorizer to vcu@yale.edu                                                                                                        VCU use only:
          Vendor Compliance Unit, 155 Whitney Avenue, 3rd floor, New Haven, CT 06511                                                                                       NEW             Vendor #:
          Phone 203-432-5060 or 436-4345                                                                                                                                   CHANGE:         Vendor #:
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Vendor Legal Name:                    Rocky & Bullwinkle Optical Lens Company, Inc.
Trade Name ("doing business as") : (if applicable)
Vendor Type: (check only one)                  Vendor *       Non-Employee           Petty Cash Custodian (PCC)                College/University                 Tax Authority

   * If "Vendor": Provider of:               Goods         Services       Goods/Services        If "Services", type of services:
Type of Organization:           (check only one)                                    Employer Identification Number:                                                  Social Security Number/ITIN:
        Individual - US citizen or US permanent resident ("green card")
        Individual - Non-US citizen and non-US perm. res. ("foreign")
        Sole Proprietorship                                                                                                                                       OR
        Partnership - US
        Corporation - US (includes 501(c)3 non-profit corporation)
        Government Agency - US
  Non-US:         Corporation          Partnership        Govt. Agency               99-7777777
Country of Permanent Residence: (non-US payees)
Mail PAYMENTS to:                                                          Mail PURCHASE ORDERS to: (if applicable)                                       Tax Reporting Site: (if different from Payment address)
Line 1:       PO Box 100                                                   Line 1:      45 Rocky Mountain Way                                             Line 1:
Line 2:                                                                    Line 2:                                                                        Line 2:
Line 3:                                                                    Line 3:                                                                        Line 3:
City:         Calgary                                                      City:        Calgary                                                           City:
State:        Alberta                 Zip:   AB1111                        State:       Alberta         Zip:       AB1111                                 State:                                Zip:
Country: CANADA                                                            Country: CANADA                                                                Country:
*Vendor Contact Information:                     Accounts Receivable - Name:                Sherman - Accounts Receivable Mgr. Phone: (555) 555-2222 Fax:
                                                 Customer Service - Name:                                                                                    Phone:                Fax:
                                                 Sales or Other - Name:   Rocky - Sales Representative                                                       Phone: (555 )555-1111 Fax:
   URL (web address) or E-mail:                  www.R&Bopticallens.com
Notes/Special Instructions:
Requester Information: Name:   Natasha                                                                      Title: Sr. Administrative Assistant              Date: 8/17/01
Department: Ophthalmology and Visual Sciences                             Phone: 5-1111                      Fax: 5-2222                 E-mail Address: natasha@yale.edu
Authorized By:                Name:      Dudley Do-Right                                        Title: Business Manager                                                                  Phone: 5-3333
Signature:                                                                 Date: 8/17/01                       AUTHORIZER: I certify that I have reviewed this request, have found it in compliance with both Yale policies and procedures and
                                                                                                               policies of any sponsoring agencies funding the activities involved, and hereby authorize the request.




   Revised 8/15/01                                                                                                                                                                                         Excel for Windows

								
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