New Vendor Registration

Complete one or more of the following:

Individual

(Not owning a business with employees)

Sole Proprietor *

Owner's Full Legal Name

Federal Tax Id for Business

# of Employees

Partnership *

Date Partnership Formed

Sub-Chapter S Corporation

Date Incorporated:

Corporation providing professional physician, nursing services, etc.*

Date Incorporated

Corporation providing legal services *

Date Incorporated

Corporation (all other)

Date Incorporated

Limit Liability Company (LLC) *

Owner's Name

Owner SSN

Federal or Virginia State Government

Local Virginia or Other State Governments

Non-profit Organization

Foreign Individual (31% will be withheld unless notified in writing of allowable exemption) *

Foreign Company (attach W-8)

* Classes which may be reportable to the U.S. Internal Revenue Service

Small Business, Women-Owned Business and Minority Business Status Information (SWAM):

Small Business Enterprise (together with affiliates, having fewer than 250 employees or $10 million annual receipts or less, averaged over the previous 3 years.)

Minority-Owned Business (51 % owned by one or more minorities, and whose management and daily business operations are controlled by such individuals.)

Woman-Owned Business Enterprise (51% owned by one or more women, and whose management and daily operations are controlled by such individuals.)

Disadvantaged Business Enterprise (51% owned by one or more socially and economically disadvantaged individuals, and whose management and daily operations are controlled by such individuals.)

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

Question: Are you already certified with the Virginia Department of Minority Business Enterprise?

Yes
No

If yes, assigned Id#

1) What are your standard payment terms?

1.5% 15, Net30 1% 10 Net 30 1% 15 Net 30 1% 20 Net 30 1% 30 Net 31 1% 30 Net 45 1% 30 Net 60 2% 10 Net 30 2% 15 Net 30 2% 20 Net 30 2% 25 Days, Net 30 Days 2% 30 Net 31 2% 30 Net 45 2% 30 Net 60 2.5% 20 Days, Net 30 2% 60 Days, Net 61 1% 30, Net 45 3% 10 Net 30 3% 15 Net 30 3% 20 Net 30 3% 30 Net 31 3% 30 Net 60 4% 15 Days Net 30 5% 10 Net 30 5% 15 Net 30 5% 20 Net 30 5% 30 Net 31 5% 30 Net 60 .5% 15 Days, Net 30 Days Net 30 Days Net 45 Days Net 60 Days Net 90 Days

2) Phone, Fax & email:

Phone

Fax

Email

3) Enter Name that you are doing business under, if different from Section A., above:

4) Enter Address where orders are placed:

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

ZIP

5) Enter Address where remittances are sent:

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

ZIP

6) List your principle products and/or services:

7) Enter your Dun & Bradstreet #:

Please observe the following guidelines when accepting orders from the University of Virginia Medical Center:

a) Always provide an invoice number on your billing document.

b) Mail all Medical Center billing documents to: Medical Center Accounts Payable Dept billing documents to:

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

c) Be aware that the Medical Center processes its purchase orders independent of the University of Virginia.

Certification (Required):

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.

Authorized Signature (type your first, middle, last name)

Title

Date

Phone #