Supplier Information Form - Case Western Reserve University
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1Submit completed, signed Supplier Information Form to-
Email scan:
customercareteam-pds@case.edu
Procurement Policy:
Fax:
Customer Care Team 216-368-5088
Mail:
Customer Care Team
10620 Cedar Avenue
Cleveland, OH 44106-4909
Supplier Information Form
In order to receive payment from Case, the recipient must be added to PeopleSoft as a vendor. All fields marked * are mandatory on the Supplier Information Form. Incomplete submission cannot be processed and will
be returned for completion. For businesses: Must be completed and signed by a designated company representative.
Supplier Information
_________________________________________________ ______________________________________________________
*Name of Company or Individual
DBA (Doing Business As), if applicable
*Supplier Type
Business Type
□ Individual
□ Partnership
□ Contractor
□ Retailer
□ Sole Proprietor
□ Non-Profit Organization
□ Distributor
□ Broker
□ Corporation
□ Government Entity
□ Manufacturer
□ Other (please specify)
_______________
□ Limited Liability Company
□ Exempt Payee
□ Small Business Concern
□ Large Business Concern
Business Size
________________________
□ Add as a new vendor to PeopleSoft
□ Update existing entry (ID or Short Name) _____________________________
*Please Check One
Supplier Diversity Information
Check all that apply (Please attach copy of SBA certification)
□
Small Business Enterprise (SBE)
□
Minority-Owned Business (MBE)
□
Disadvantaged Business Enterprise (DBE)
□
HUB Zone - Historically Underutilized Business Zones
□
Disabled Veteran Business Enterprise (DVBE)
□
HBCU / MI
□
Women-Owned Business Enterprise (WBE)
□
________________________________
Other (please specify)
Supplier Business Addresses & Payment Information
*Remit to Address – Payment will be mailed here
_________________________________________________________________________________________________________
*Address (Number, Street, and Apt or Ste number)
_______________________________________ ___________________________________ _____________________________
*City
*State
*Zip Code
_______________________________________ ___________________________________ _____________________________
*Email Address
*Phone Number
Fax Number
________________________
Supplier’s Address (if different than address above) –or – Previous Address (if updating existing PeopleSoft entry)
_________________________________________________________________________________________________________
Address (Number, Street, and Apt or Ste number)
_______________________________________ ___________________________________ _____________________________
City
State
Zip Code
________________________
□ Yes
□ No
□ Yes
□ No
Businesses, Do You Accept Credit Card Payments?
Ecommerce / PeopleSoft?
Supplier Contact at Case Western Reserve University
______________________________________ ___________________________________________ ________________________________
*Case Contact Name
*Contact Email
*Contact Phone
__________________________________ _____________________________________________________________________
*Contact Department
*Contact Signature
W9 Certification of Supplier Information
The IRS requires that you provide information which allows us to complete 1099 reporting.
W9 Certification: Under penalties of perjury, I certify that the number shown on this form is my correct
Your payments may be subject to backup withholding if you fail to provide a correct Taxpayer
Taxpayer Identification Number, and I am not subject to backup withholding as a result of a failure to
Identification Number (TIN).
report all interest or dividend income, and I am a US citizen or US person.
Note: US Persons filling out this form do NOT have to fill out a W-9, non US Persons must
fill out a W-8BEN in addition to this form.
*Please enter your TIN (SSN or EIN) below
____________________________________________
______________________________________ *Sign Here
*Date _____________________
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