The Assignment of Delinquent Municipal Tax and Sewer Liens of the City of West Haven

VENDOR APPLICATION FORM
Please ensure a W-9 form is attached to this request. Please fill out this form
completely as instructed, sign (with blue ink) (electronic signatures are not
accepted) and email the procurement department. Please fill out all sections
highlighted in green.
Section 1. Vendor Information
Date Requested (mm/dd/yyy)
Is This A New Vendor Or Vendor Modification (Type As "N" Or "Vm")
If This Is An Existing Vendor Modification, Please Provide The Vendor No.
Type Of Vendor Modification (i.e address change, remit add, remit
change, etc))
FEIN Tax Id or Social
Company / Firm Name As Shown On Federal Tax Return
Security w/dashes
Unique Entity Id (Uei)
Doing Business As (Dba) Name If Applicable (also attached DBA Certificate) Required For Federal Awards /
Grants
Business Place Of Incorporation/Registry Cage Number
Address CT Business ALEI #
City State Zip
Section 2. Payment and Remit Address
Address
City State Zip
Section 3. Vendor Contact Information
General Contact(S)
Name TITLE PHONE EMAIL
Authorized Signer(S) - Individuals Who Can Bind/Sign Agreements/Contracts
Name TITLE PHONE EMAIL

Section 4. Additional Vendor Information
Is your business/corporation to receive a 1099 at end of the year? Yes No
Are you considered a small business? Yes No
Are you considered a Minority Owned business? Yes No
Section 5. Name of individual completing the form
Name
Title
Email
Signature
Requests will not be processed without all fields accurately filled out and proper
documentation. By signing this form, I am certifying that all information
submitted is correct. Please ensure to sign this form in Blue Ink.
Section 6. Internal Employee Information
If marked yes, Please Provide Their Department And
Is This An Employee Of The City Or Boe?
Employee Number
YES DEPARTMENT
EMPLOYEE
NO
NO.
Section 7. Internal Use Only - To be completed by City of West Haven
Vendor Number
Date Received
Date Processed
Employee who
processed
2