Request for Vendor Information Form

GENERAL INFORMATION

Payment/Discount Terms

2% 20 Net 30
2% 10 Net 30
1% 20 Net 30
1% 10 Net 30
Net 30
Other

BUSINESS STATUS INFORMATION

Please select the appropriate response below:

Business Status (select one) *

Corporations, Partnerships & Trusts
Individual
Sole Proprietors using an assumed business name

PRODUCTS OR SERVICES YOUR COMPANY PROVIDES

ADDITIONAL DATA

Indicate if minority or woman owned (more than 51%) *

Ethnicity of Owner(s)

African-American
Asian-Indian
Asian-Pacific
Hispanic
Native American
Other

LIST 3 CREDIT REFERENCES

INFORMATION PROVIDED BY

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