NEW VENDOR FILLABLE TEMPLATE

Rev. Form 03/2014

Date of Request (mm/dd/yyyy):

A. General Information (Type of Request)
✘ A1. New Vendor A2. Activate/Modify Vendor A2.1 Current Vendor #:
A3. Motives to modify a vendor: A3.1 Update Permanent Address A3.2 Add Bank Information
A3.3 Update Company or Person Name A3.4 Add Pay Site
B. Vendor / Supplier Information
Vendor Type: Company Non Company
B1. Company Name:
B2. Contact Name: B3. Contact Title:
B4. Contact Extension#:
B5. Is your Company? a Small Business a Minority-Owned a Women-Owned N/A
B6. Last Name 1: B7. Last Name 2:
B8. First Name: B9. Middle Name:
B10. Name as Shown in ID Doc.:
B11. Phone Number: B12. Email:
B13. Nationality: B14. Type of ID:
C. Vendor / Supplier Permanent Address
C1. Permanent Address:
C2. City: C3. State/Province/Department/Other:
C4. Country: C5. Postal Code (Required for US/Canada addresses):
D. Banking Info – Required for Wires and Electronic Payments
1. Wire Payment: 2. Electronic Payment: N/A
D1. Bank Name:
D2. Bank Address:
D3. Bank contact phone: D4. Branch Name:
D5. Branch Number: D6. Account #:
D7. Name on Account:
D.A. Wire Payment Specific Information European Bank
DA1. Routing / Swift code (BIC): DA2. IBAN#:
An Intermediary Bank is needed?: YES NO
DA3. Intermediary Bank Name:
DA4. Intermediary Bank Account #:
DA5. Intermediary Bank Routing / ABA#:
D.B. Electronic Payment Specific Information
DB2. Bank Routing / ABA#: N/A
Checking Account: Saving Account: :
E. Additional Pay Sites for payment purpose
E1. Pay Site 1 info: E2. Pay Site 2 Info:

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