New Vendor Registration

SUBSTITUTE FORM W-9 AND VENDOR REGISTRATION

ATTENTION -
Tax, Legal or Accounts Receivable (QUICK RESPONSE WILL PREVENT PAYMENT DELAY)

(Required)
(Social Security Number if Individual or Sole Proprietor)


(Not owning a business with employees)

Minority Business Enterprise Certification: To be included in benefits of State procurement opportunities, entities must be certified by the Commonwealth of Virginia. However, no vendor shall be required to certify under this program and no vendor shall be excluded from doing business with the Commonwealth because of their failure to become certified. For information regarding certification, contact the Virginia Department of Minority Business Enterprise, 200 N 9th St., Richmond, VA 23219 or call (804) 786-5560 from 8:00am to 5:00pm or access their website at www.dmbe.state.va.us



(Required)

P.O.Box 800779
Charlottesville, Virginia 22908-0779

Under penalty of perjury, I certify that all of the information provided on this form is correct, and that:

(1) The number(s) shown on this form are the correct taxpayer number(s) and the names indicated are the legal names on file with the IRS or SSA.

(2) I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding or the IRS has notified me that I am no longer subject to backup withholding. ( Check here if you have been notified by the IRS that you are currently subject to backup withholding.)

(3) I am a U.S. person (including a U.S. resident alien).

(4) Neither I nor any immediate family member is currently an employee of the University of Virginia, University of Virginia Medical Center or any other state agency of the Commonwealth of Virginia. "Immediate family" means (i) a spouse and (ii) any other person residing in the same household with you, who is your dependent or of whom you are a dependent. A "dependent" means a son, daughter, father, mother, brother, sister or other person, whether or not related by blood or marriage, if such person receives from you, or provides to you, more than one-half of his or your financial support. If you or an immediate family member are an employee, please call our Director of Procurement at (434) 982-3865 for guidance.

Note: Upon successful submission of this form a confirmation page will be displayed. If you do not see the confirmation page after pressing the submit button, your submission was not successful. Please resubmit.

A copy of this form submission will be sent to the submitter email address.