Vendor Application
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1
2LCSC Use Only: Requested By: __________________________________
Regular Vendor__________ One-Time Vendor__________
Vendor Application
Legal Name:
Business Name (dba)
Tax Identification Number (TIN/EIN):
Type of Business: (circle one) Individual, Sole Proprietor, Partnership, Corporation, Non-Profit, Trust/Estate, LLC (C=C Corporation,
S=S Corporation, P=Partnership)
Other (specify)
Historically Underutilized Business*:
Yes
No
Type:
select
Choose an item.
*Attach copy of HUB certificate, if applicable
ADDRESS INFORMATION
Business Address
Address 1:
City:
State:
Zip:
Phone:
FAX:
*Email:
*R
equired – All Purchase Orders are sent via email to the vendor. Please reference the PO number on all invoices to ensure timely payment
Remit Address (check receiving)
Address 1:
City:
State:
Zip:
Phone:
FAX:
Email:
Not required
Additional: Specify:
Address 1:
City:
State:
Zip:
Phone:
FAX:
Email:
Not required
VENDOR CONTACT
Name:
Title:
Website:
Email:
Phone # if different than above:
Does vendor accept returns?:
Yes / No
Does vendor accept pro-card?
Yes / No
Is 1099 Withholding applicable?
Yes / No
LSCS Relationship to Tax Payer/Vendor
•
Does an LSCS employee work for this entity? Yes__________ No___________
If yes, provide name ________________________________________________
•
Does an LSCS employee or his or her family member own a five percent (5%) or greater interest in this entity? A family member means a
spouse, child (natural, foster, or step), in-law, sister, brother, mother, father, or grandparent?
Yes____________ No______________
Certification
Under penalties of perjury, I certify that:
1.
The number shown on this form is my current taxpayer identification number, and
2.
I am not subject to back-up withholding because: (a) I am exempt from back-up withholding, or (b) I have not been notified by the
Internal Revenue Service that I am subject to back-up withholding as the result of a failure to report all interests & dividends, or (c)
the IRS has notified me that I am no longer subject to back-up withholding and
3.
I am a U.S. Citizen (including a U.S. Resident Alien).
The Internal Revenue Service does not require your consent to any provisions of this document other than the
certifications required to avoid backup withholding.
Signature
Print Name
Date______
***Once vendor entry has been made, a link and instructions will be sent to the email address provided on this
form. Please offer this information to your sales representative for registration.
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Parent category: Business