Vendor Management Form (Peoplesoft Financial System) - State Of Georgia

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VENDOR MANAGEMENT FORM (PeopleSoft Financial System)

The initiating Agency will submit this form to the Vendor Management Group for verification and approval. Agency must

complete section 5 of the form to obtain approval.

SECTION 1 – VENDOR IDENTIFICATION (COMPLETE ALL APPLICABLE FIELDS)

VENDOR NUMBER: _________________________________ _ ___

FEI/SSN/EMP ID NUMBER:________________________________

VENDOR NAME: _______________________________________________________________________________________________

PAYMENT ALT NAME: (IF CHECK IS TO BE PAYABLE IN A DIFFERENT NAME) ________________________________________________

ADDRESS:_____________________________________________________________________________________________________

ADDRESS CONT:________________________________________________________________________________________________

CITY: ________________________________STATE:__________________ZIP CODE: __________________ COUNTRY:______________

PHONE NUMBER: ________________________________________FAX NUMBER: ___________________________________________

EMAIL: ________________________________________________________________________________________________________

SECTION 2 – BANK ACCOUNT INFORMATION (ATTACH COPY OF VOIDED CHECK)

ROUTING #_________________________________ BANK ACCOUNT #____________________________________

Check here if General Bank Account can be used by ALL State of Georgia agencies making payments

Check here if this account can only be used for a SPECIFIC purpose_________________________________________

(Indicate specific purpose for which this account can be used)

I authorize the State of Georgia to deposit payment for goods or services received into the provided bank account by the Automated Clearing House (ACH). I further

acknowledge that this agreement is to remain in full effect until such time as changes to the bank account information are submitted in writing by the vendor or individual

named above. I understand it is the sole responsibility of the vendor or individual to notify the State of Georgia of any changes to the bank account information.

_______________________________________

_________

(Vendor Printed Name)

(Vendor Signature)

(Date)

SECTION 3 – SPECIFY TYPE OF ACTION (CHECK ALL THAT APPLY)

New Vendor

Employee

1099 Code____________________

Classification Change ___________________ Add address

FEI/TIN Change**

Name Change**