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Dunn County Financial Division

3001 US Highway 12 East Suite 225 Menomonie, WI 54751

(715) 232-2429

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

Dunn County Department or Person of Contact

Bank Information for Electronic Payments

Account Type

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