This form contains 15 fields organized into 4 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
General
Vendor Name 1 Text
Remittance Address [1 Text
Remittance Address [2 Text
Property Information
Is Vendor Incorporated? Yes Checkbox
Check this box if the vendor is incorporated.
Is Vendor Incorporated? No Checkbox
Check this box if the vendor is not incorporated.
Vendor Agreement
Vendor Printed Name Text
Provide the printed name of the vendor.
Agreement Date Date
Provide the date of the vendor agreement.
Vendor Information
Remittance Address Text
Enter the full remittance address for the vendor.
Vendor Fax Text
Provide the vendor's fax number.
Vendor Phone Text
Provide the vendor's primary phone number.
Vendor Email Text
Enter the vendor's email address.
Federal Tax ID Text
Enter the vendor's Federal Tax Identification Number (EIN).
Name on SSN Text
Provide the name associated with the Social Security Number.
SSN Text
Provide the Social Security Number.
Type of Business Text
Specify the vendor's type of business (e.g., corporation, sole proprietorship).