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

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.

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