SUBSTITUTE FORM W-9 AND VENDOR REGISTRATION
ATTENTION - Tax, legal or Accounts Receiveable (QUICK RESPONSE WILL PREVENT PAYMENT DELAY)

Your Email Address

1. Substitute Form W-9 Information (Required)

   Legal Name (must agree with IRS forms)

   Legal Address

   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

   Zip

   Federal Tax ID Number (Social Security Number if Individual or Sole Proprietor)

   Is this an SSN?
   Yes, this is SSN (Individual)
   No, this is FEIN (Employer)
   

   Complete one or more of the following
   

   • Individual

   • Sole Proprietor *

     Owner's Full Legal Name

     Federal Tax ID for Business

     # of Employees

   • Partnership *

     Date Partnership Formed

   • Sub-Chapter S Corporation

     Date Sub-Chapter S Incorporated

   • Corporation providing professional physician, nursing services, etc. to patients *

     Date Professional Services Incorporated

   • Corporation providing legal services *

     Date Legal Services Incorporated

   • Corporation ( all other )

     Date Other Corporation Incorporated

   • Limited Liability Company ( LLC ) *

     LLC Owner's Name

     LLC Owner's SSN

   • Federal or Virginia State Government

   • Local Virginia or Other State Government

   • Non-profit Organization

   • Foreign Individual ( 28% 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

2. If you are doing or intend to do business in Virginia, check one or more of the following, if applicable.

   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.)

   • Micro-business: a certified small business that has no more than twenty-five (25) employees and no more than $3 million in average annual revenue over the three-year period prior to certification.

   • 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?

   • If yes, assigned ID #

3. Other Registration Information

   • What are your standard payment terms? Net 30 Days 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 45 Days Net 60 Days Net 90 Days

   • Phone, fax and email

     Phone

     Fax

     Business email

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

   • 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

     Zip

   • 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

     Zip

   • List your principal products and/or services

   • Enter your Dun & Bradstreet #

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

     1. Always provide an invoice number on your billing document.
     2. Mail all Medical Center billing documents to: Medical Center Accounts Payable:
        
        P.O.Box 800779
        Charlottesville, Virginia 22908-0779
        
     3. Be aware that the Medical Center processes its purchase orders independent of the University of Virginia.

   
   
   Certification (Required)
   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