Section 1 of 1 in this document

Vendor Data Form

Main Address Data

*Is a required field and must be filled out for form to be submitted.

Company Name or DBA

Contact Name

Country

Phone Number

2nd Phone Number

Fax Number

TIN or SSN - Tax Number 1 (no dashes)

TIN or SSN - Tax Number 2 (no dashes)

Entity Designation (please mark one)

Individual/Sole Proprietor

Corporation (includes service corporations)

Limited Liability Company - Partnership

Limited Liability Company - Sole Proprietor

Limited Liability Company - Corporation

Government Entity

Hospital Exempt from Tax or Government Owned

Long Term Care Facility Exempt from Tax or Government Owned

All Other Entities

If you checked Corporation under Entity Designation - Are you engaged in the business of providing medical services?

Yes

Do you provide a Service or a Product?

Service

Product

Please list the Service or Product you provide.

Remittance if Different from Main

Is this information the same as the Main Address Data?

Yes - please go to payment terms below

No - please fill in Remittance if Different form Main information below

Company Name or DBA

Contact Name

Country

Phone Number

2nd Phone Number

Fax Number

Payment Terms

Other Payment Terms

Payment Method

Bank Information for Electronic Payments

ACH Verification may take 7 -10 business days.

No payments will be issued until ACH information is authenticated.

Financial Institution Name

Bank Routing Number

Bank Account Information

Account Holder Name

Bank Account Country if not US

Upload File(s) - Bank Confirmation Letter or Cancelled Check (please do not upload bank statement)

Account Type

Checking

Savings

Dunn County Department or Person of Contact

Department and Employee Contact

Dunn County Department *

Name of Dunn County Employee *

Upload File(s) - W9

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Vendor Data Form

Main Address Data

Full Name

Full Address

Entity Designation (please mark one)

If you checked Corporation under Entity Designation - Are you engaged in the business of providing medical services?

Do you provide a Service or a Product?

Remittance if Different from Main

Is this information the same as the Main Address Data?

Full Name

Full Address

Bank Information for Electronic Payments

Financial Institution Address

Upload File(s) - Bank Confirmation Letter or Cancelled Check (please do not upload bank statement)

Account Type

Dunn County Department or Person of Contact

Department and Employee Contact

Upload File(s) - W9

Sign Here