LEGAL NAME

FEDERAL ID / SSN

D D/B/A

OWNERSHIP TYPE COMPANY OFFERS

BUSINESS CATEGORIES CATEGORY 2

STREET 1

STREET 2

CITY

ZIPSTATE

PHONE EXT. EXT.

DISCOUNT DAYS

BANK NAME

ACCOUNT NO.

ACCOUNT TYPE

ROUTING NO.

BANK EMAIL

PRINTED NAME

POSITION TITLE

SIGNER EMAIL

DISCOUNT INFORMATION

EFT/ACH PAYMENT INFORMATION

NEW VENDOR REGISTRATION FORM

GENERAL INFORMATION

Per Florida Statute 119.71(5), HCD is required to notify individuals of the circumstances that require or authorize the collection and use of social security numbers (“SSN”). HCD is requesting the information above, as required for income tax reporting purposes.

VENDOR AUTHORIZATION

COMPLETE FORM AND RETURN WITH CURRENT YEAR W9 TO REQUESTOR

REMIT TO ADDRESS

CATEGORY 3

STREET 1

STREET 2

PURCHASING ADDRESS

SIGNATURE

PO EMAIL

CATEGORY 1

DISCOUNT PERCENT

PHONE

PAYMENT METHOD

DATE

CITY

ZIPSTATE