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Vendor Information Form

2. Please complete this form and return it to:

   Purchasing Agent, City Hall Room 105 <br> 100 Broadway, Norwich, CT 06360-4431<br> Phone: (860) 823-3706 Fax: (860) 823-3812<br>

   Purchasing Agent, City Hall Room 105
   100 Broadway, Norwich, CT 06360-4431
   Phone: (860) 823-3706 Fax: (860) 823-3812
   

4. Legal business name:*

   If you are an individual or sole proprietor, the individual's name as the owner must appear as the Legal business name.

5. Doing business as (DBA) name

7. Business Entity Type*
   -- Select One --CorporationNon-ProfitPartnershipIndividual/ Sole ProprietorLLC taxed as a CorporationLLC taxed as a PartnershipSingle-member LLCOther - please describe

8. Entity Description

10. Tax Identification Number*

11. State of Incorporation

13. Business Type*
    -- Select One --Sale of CommoditiesMedical ServicesLegal ServicesRental of PropertyOther (please describe)

14. Business Type Description

16. Sales Contact Information

18. First Name*

19. Middle Initial

20. Last Name*

21. Suffix

23. Do you accept purchase orders by:

    1. Mail
    2. Fax
    3. Email

24. Email Address*

25. Phone Number*

26. Fax Number

28. Street Number

29. Street Name

30. Street Type

31. Apt/ Suite #

33. City

34. State

35. Zip

37. Sales discounts

39. Cash Discounts

42. Accounts Receivable Contact Information

    Please fill in this section if it differs from the Sales Contact Information

    Please fill in this section if it differs from the Sales Contact Information

44. First Name

45. Middle Initial

46. Last Name

47. Suffix

49. Street Number

50. Street Name

51. Street Type

52. Apt/ Suite #

54. City

55. State

56. Zip

57. Phone Number

59. Fax Number

60. Email address

61. City's Vendor Number

63. Bank Name

64. Bank Routing #

65. Bank Account #

67. All ACH/EFT payments will be to a checking account.

    All ACH/EFT payments will be to a checking account.

69. All goods, materials, equipment, and or services purchased under a purchase order requires the vendor to accept payment of funds in electronic form.

    All goods, materials, equipment, and or services purchased under a purchase order requires the vendor to accept payment of funds in electronic form.

Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit Submit and Print

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