Fillable Printable New Vendor Registration - Monroe

New Vendor Registration - Monroe

NVR (Rev. 06/10)

New Vendor Registration

Monroe County Purchasing Department Print Form

200 County Office Building

39 West Main Street

Submit by Email

Rochester, NY 14614

the completed form to Purchasing & Central Services (585-753-1104).

Vendor Name:

REMIT TO ADDRESS INFORMATION:

Number & Street:

Street 2:

City/Town: State: Zip: Country:

Phone (no spaces): Cell Number (no spaces):

PURCHASE ORDER ADDRESS INFORMATION:

Number & Street:

Street 2:

City/Town: State: Zip: Country:

Email: Fax:

VENDOR TAX INFORMATION (Either SSN or Federal Employer ID Number):

SSN: OR FEIN #:

MINORITY AND WOMEN'S BUSINESS ENTERPRISE INDICATOR:

Are you a minority- or woman-owned business?

Minority Business Enterprise (MBE) Minority/Women-Owned (MW)

Women-Owned Business Enterprise (WBE)

If yes, please enter the following: Certification Date:

AND

VETERAN BUSINESS INDICATOR:

Are you a veteran-owned business?

Veteran-Owned Business

Service Disabled Veteran-Owned Small Business (SDVOSB)

PURCHASING DATA:

Shipping Terms: (e.g., FOB Destination)

Salesperson:

Phone Number:

Vendor's Account Number:

INDICATE MATERIAL GROUP(S) ON PAGE TWO.

Please email (mcpurchasing@monroecounty.gov) or print and fax

Witholding Tax Code:

NVR (Rev. 06/10)

IDENTIFY PRODUCTS OR SERVICES COMPANY PROVIDES:

Code & Description:

New Vendors must review the Material Groups listing (http://www.monroecounty.gov/purchasing/materials) on

the left navigation menu and identify the number and name of the material group(s) their company is able to

provide in the areas below. Upon completion and submission, you will receive an e-mail notification that your

company information was recorded. You must enter at least one material group code and description.