Vendor Registration & Substitute W-9
     
  * Required Fields    
     
   
Vendor Name (Check Made Payable): *  
     
     
Vendor Type: *  
 

      
 
     
     
Legal Name:
(must be as appears on SS card or tax return)
*  
     
Taxpayer Identification Number: *
 
     
Are You Exempt From 1099 Reporting? *
(If yes, select qualifying reason below)
   
     
If Claiming Exemption, You Must Select a Qualifying Reason:  
 



 
 
     
Remittance Address:    
Street Address/PO Box: *  
     
Suite:  
     
City: *    
     
State: *    
     
Zip: *    
     
Contact Name: *  
     
Contact Phone Number: *   999-999-9999    
     
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 witholding, or  
   (b) I have not been notifed by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to
         report all interest or dividends, or
 
   (c) the IRS has notified me that I am no longer subject tobackup witholding, and  
3. I am a U.S. person (including a U.S. resident alien).  
 
Signature:
(typing in your name acts as your signature)
*  
 
The date and time of submisson, and your computer's IP address will be recorded when you click Submit.