City Of Pickerington Vendor Information Form, Form W-9, Independent Contractor Acknowledgment


Vendor Information
Please complete this page and W-9 and return with Ohio BWC documentation to 100 Lockville Road,
Pickerington, OH 43147; Fax 614-833-2201. Independent Contractors must also complete the attached
OPERS acknowledgement.
Name ________________________________________________________________________________
Address ______________________________________________________________________________
City ______________________________
State ________________
Zip ________________
Phone __________________________________
Fax ____________________________________
Contact ______________________________________________________________________________
Email ________________________________________________________________________________
Type of Work Performed ________________________________________________________________
Terms: Please check what type of discount applies if paid within a certain amount of days or period of
time payment must be made.
_____ 1% Net 30 Days
_____ Net ½%
_____ 2% Net 30 Days
_____ Net 10 Days
_____ Net 15 Days
_____ Net 0 Days
_____ No terms
_____ Net 30 Days
_____ Other ______________________
FED EIN or SS# ________________________________________________________________________
If vendor is company, is it incorporated?
_____ Yes
_____ No
Vendor is Sole Proprietor
_____ Yes
_____ No
Note: All above must be completed in order for vendor to be put on system.
If vendor is performing work and has employees on City Premises, a Bureau of Workers Compensation
Certificate must be submitted to the City before vendor is added to the system.


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