Vendor Request Form

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VENDOR REQUEST FORM
**ALL FIELDS MUST BE COMPLETED**
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NEW
ADDRESS CHANGE
VENDOR INFORMATION (please do not leave anything blank)
Vendor Business Name:
_________________________________________________________________________________
Vendor Contact/Rep Name:
_______________________________________________________ _______________________
Community Requesting Setup:
____________________________________________________
Product/Service Category:
_______________________________________________________________________________
Vendor Service Area:
____________________________________________________________
VENDOR TYPE (please check all applicable boxes)
□
□
□
INCORPORATED
PARTNERSHIP
SOLE PROPRIETORSHIP
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NON-PROFIT
SMALL BUSINESS
INDEPENDENT CONTRACTOR
□
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LOCAL GOVERNMENT
FEDERAL AGENCY
PARTNERSHIP
VENDOR ADDRESS
REMIT TO ADDRESS
STREET / P.O. BOX
STREET / P.O. BOX
CITY
STATE/ZIP
CITY
STATE/ZIP
PHONE
PHONE
FAX
BUSINESS EMAIL
BANK INFORMATION (for direct deposit use only)
Bank Account
Number____________________________________________
Routing
Number_________________________________________________
Remit to
Email___________________________________________________
AUTHORIZATION
Avesta Teammate
Signature/Date_______________________________________
Avesta Supervisor
Signature/Date_______________________________________

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Parent category: Business
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