Supplier Information Sheet - First Line Technology
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Supplier Information Sheet
Please complete this form and fax or email it along with a current W-9 to accounting at 703-955-7540 or .
Your company cannot be set up without the receipt of a completed supplier information form and current W-9.
Supplier Information
Supplier Name: _________________________________________________________________________________________________________________________
Address: _____________________________________
P.O. Box: ____________________
City, State, Zip:____________________________________
Main Phone: _________________________________________________________________________ Fax: _______________________________________________
Remittance Address
Address: _____________________________________________________________________________ P.O. Box: __________________________________________
City: ________________________________________________________________________________ State: ______________ Zip: __________________________
Product Return Address
Address: ________________________________________________________________________________________________________________________________
City: ________________________________________________________________________________ State: ______________ Zip: __________________________
Key Contacts
Customer Service Contact: ____________________________________________________________ Title: ______________________________________________
Phone: _____________________________________________________________________ Email: _____________________________________________
Accounting Contact: __________________________________________________________________ Title: ______________________________________________
Phone: _____________________________________________________________________ Email: _____________________________________________
Sales Contact: _______________________________________________________________________ Title: ______________________________________________
Phone: _____________________________________________________________________ Email: _____________________________________________
Alternate Contact: ___________________________________________________________________ Title: ______________________________________________
Phone: _____________________________________________________________________ Email: _____________________________________________
General Information
(Please answer all questions)
Vendor Type:
Manufacturer
Distributor
Service Provider
Diversity Ownership:
Minority
Woman
Disabled Veteran
Other _________________________________________
What is your minimum order quantity or minimum dollar value (if any)?__________________________________________________________________________
What are your payment terms? (Our standard terms are Net 30) __________________________________________________________________________________
Will you drop ship to customers?
Yes
No
Drop ship fee, if applicable: _________________________________________________
Do you offer prepaid freight?
Yes
No
Minimum PO value for prepaid freight: _______________________________________
Do you have insurance coverage?
Yes
No
If yes, please send Certificate of Insurance with form.
Type of insurance coverage:
Product Liability
General
**If you are supplying materials to First Line Technology, LLC, please list us as additional insured before supplying.**
Do you have a certified quality program?
Yes
No
If yes, what is its name? ____________________________ Exp. Date: ____________
If no, list Qualification Reason: ____________________________________________
Warranty and Return Policy: _______________________________________________________________________________________________________________
Briefly describe your product and/or service offering: _________________________________________________________________________________________
Signature: __________________________________________________________
Date: ________________________________
FOR OFFICE USE ONLY
Date Received: _________________________
First Line Technology, LLC
Supplier Number: _______________________
3656 Centerview Drive, Suite 4 | Chantilly, Virginia 20151 USA
Approved: _____YES
_____ NO
Tel: 703.955.7510 | Fax: 703.955.7540 | Toll Free: 866.556.0517
Approved by: ___________________
Rev 3_01222015
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Parent category: Business