Form 47228 - Application For Vendor Registration - State Of Indiana
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4APPLICATION FOR VENDOR REGISTRATION
Vendor #______ (IDOA use only)
State form 47295 (R7 / 04-01)
State of Indiana
Department of Administration and Department of Transportation
Procurement Divisions
402 West Washington Street, Room W468
Indianapolis, Indiana 46204
(317) 232-3053
PLEASE TYPE OR PRINT IN BLACK INK.
The W-9 form is required. Disclosure of your Federal Identification number or Social Security number is
needed in order to expedite processing of your application. YOUR APPLICATION WILL BE CONSIDERED
INCOMPLETE IF THE W-9 AND THE COMMODITY LIST IS NOT INCLUDED. A W-9 IS REQUIRED
FOR THE REMIT TO LOCATION ONLY.
OUT-OF-STATE CORPORATIONS:
All out-of-state corporations must be registered with the Indiana Secretary of State before they can be awarded a
purchase order or enter into a contract with the State of Indiana. Registration with the Department of
Administration, Procurement Division, does not include Secretary of State registration. For further information
and applications, please visit their web site at
.
MINORITY BUSINESS ENTERPRISES:
Registration with the Department of Administration, Procurement Division, is not connected with the
certification process of the Minority Business Development Division. For more information, please contact the
Minority Business Development office at 317-232-3061.
I.
NAME OF COMPANY AND REMIT TO ADDRESS (PAYMENT ADDRESS)
Company Name
____________________________________________________________________________________________
Number and street
City
State
____________________________________________________________________________________________
County
Zip Code
______________________________________________(
)_____________________(
)
_____________
Contract person
Telephone number
Fax number
____________________________________________________________________________________________
E-Mail Address
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