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Vendor Information Form

2. By using the submit button, your information will be sent electronically. If you prefer not to use that method, then please complete this form and return it to:
   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
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.
69. 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:


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

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field