Fillable State Of Nevada Vendor Registration printable pdf download

CLEAR FORM

Mail or fax to:

STATE OF NEVADA

STATE CONTROLLER’S OFFICE

555 E WASHINGTON AVE STE 4300

VENDOR REGISTRATION

LAS VEGAS NV 89101-1071

PHONE: 702/486-3810 or 702/486-3856

FAX: 702/486-3813

All sections are mandatory and require completion. IRS Form W-9 will not be accepted in lieu of this form.

NAME For proprietorship, provide proprietor’s name in first box and DBA in second box.

Doing Business As (DBA)

Legal Business Name, Proprietor’s Name or Individual’s Name

ADDRESS/CONTACT INFORMATION

Address A – Physical address of

Address B

Company Headquarters

Individual’s Residence

Additional Remittance – PO Box, Lockbox or another physical

Is this a US Post Office deliverable address?

Yes

location.

Address

City

State

Zip Code

City

State

Zip Code

E-mail Address

Phone Number

Fax Number

Phone Number

Fax Number

Primary Contact

ORGANIZATION TYPE AND TAX IDENTIFICATION NUMBER (TIN) Check only one organization type and supply the applicable

Social Security Number (SSN) or Employee Identification Number (EIN). For proprietorship, provide SSN or EIN, not both.

Individual (SSN)

LLC tax classification:

SSN

Sole Proprietorship (SSN or EIN)

Disregarded Entity

Partnership (EIN)

Partnership

Name associated with SSN:

Corporation (EIN)

Corporation

EIN

Government (EIN)

Tax Exempt/Nonprofit (EIN)

Yes – Provide previous TIN & effective date.

New TIN?

Trust/estate (SSN or EIN)

Previous TIN:

Date:

OTHER INFORMATION Check all that apply.

Doctor or Medical Facility

In-State (Nevada)

Nevada Business License Number:

Attorney or Legal Facility

DBE Certificate #:

Per NRS 227, payment to all payees of the State of Nevada will be electronic.

ELECTRONIC FUNDS TRANSFER

Complete the following information AND provide a copy of a voided imprinted check for the account. If there are no checks for the account, restate

the bank information on company letterhead. Individuals may provide a signed letter. A deposit slip will not be accepted. For a savings account,

provide a signed letter with the bank information. Information on this form and the support documentation must match. Allow 10 working days for

activation.

The information is for address

Both

Bank Name

Bank Account Type

Provide an e-mail address for receiving Direct Deposit Remittance

Checking

Savings

Advices.

Transit Routing Number

Bank Account Number

Do not have a bank account.

IRS FORM W-9 CERTIFICATION AND SIGNATURE

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS)

that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup

withholding, and

3. I am a U.S. citizen or other U.S. person (as defined by IRS Form W-9 rev January 2011).

Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and

dividends on your tax return.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Signature

Print Name & Title of Person Signing Form

Date

FOR STATE CONTROLLER’S OFFICE USE ONLY

Name of State agency

Primary 1099 Vendor

1099 Indicator

Yes

contact & phone number:

Entered By

Date

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