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Vendor Profile & Substitute W-9 Form

Basic Information
Company Name
Address
City State Zip
Telephone Fax  
Website  
State/Country of domicile/incorporation   
Location of company's headquarters or principal place of business  
   
Name of parent or holding company
Address of parent or hold company (if applicable)  
 
       
Tax Information and W-9
Federal Tax ID number
Social Security Number
Form of Business:  
Corporation Partnership Sole Proprietor/Individual
Check here if exempt from backup with-holding
   
       
Business Certification
State of Indiana - certification #
City of Indianapolis - certification #
Other (please specify)
Not certified (move to self-declaration section)
Under what category are you certified?
African American Hispanic Woman owned Native American
Asian Veteran-owned Disadvantaged business enterprise
Small business enterprise Other (specify)
       
Self-declared
If you are not certified, can you self-declare yourself as any of the following?
African American Hispanic Woman owned Native American
Asian Veteran-owned Disadvantaged business enterprise
Small business enterprise Other (specify)
       
If you checked any of the above, have you ever considered becoming certified by the State of Indiana?       Yes    No
       
After submitting this form, you will need to print, sign and fax to 260-436-3177, or mail to 5701 Coventry Lane, Fort Wayne IN  46804.

 
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