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Vendor Application Form

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Please enter the information below, then select the "Printable Form" button below to return a page which is your Vendor Application form. Print the form, sign it, and fax it to Grant and Contract Services at (508) 457-2189  or scan and email to creid@whoi.edu.
  Vendor Information
  Name:   TIN/SSN:

  Business Mailing Address
  Address:
  City:   State:   Zip:
  Phone:   Fax:
  Contact:   Email:

  Invoice Remittance Address
  Address:
  City:   State:   Zip:
  Phone:   Fax:
  Contact:   Email:

Required
Vendor Authorized Signer Name: ________________________   Phone: ________________
Vendor Signature: ____________________________________   Date: _____/_____/_____
 
  Tax and Withholding Information (please select one)
  Corporation   Partnership
  Medical Corporation   Non-Resident
  Sole Proprietorship/Independent Contractor   Government Entity
  Tax Exempt Organization under IRS (501) Rules   1099

  Business Type Classification (please check all that apply)
  American Indian Owned   Veteran Owned Business
  HUB Zone Firm*   Service Disabled Veteran Owned
  Small Business   Disabled
  Large Business (500+)   Nonprofit Organization
  Disadvantaged Business**   Sheltered
  Woman Owned Business   Foreign Supplier
  Limited Liability Company   Historically Black College/University
 
  *FAR Clause 52.219-1(d) (2) Under 15 U.S.C 645(d), any person who misrepresents a firm’s status as a small, HUBZone small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act or any other provision of Federal law that specifically references sections 8(d) for a definition of program eligibility, shall: (i) Be punished by imposition of fine, imprisonment or both; (ii) Be subject to administrative remedies, including suspension and debarment and (iii) Be ineligible for participation in programs conducted under the authority of the Act.
 
  **Hub Zone and Small Disadvantaged Business must provide a copy of their certificate with this form.

  Purchasing Key (please select one)
  Maintenance   Distibutors
  Office Supplies/Furniture   Transportation Services
  Building trades/Contractors   Computer Supplies
  Manufacturers   Marine/Rigging Shop Supplies
  Electronics   Services
  Other

 


Last updated: January 14, 2014
 


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