Businesses Vendor Request Form - Complete

Business New Vendor Request Form

Instructions: This application is for Businesses Only, including corporations, partnerships, sole proprieters, LLCs, etc. These are entities that have a Federal Employer Identification Number (FEIN), rather than use of a SSN. To be accepted, this form must be submitted along with the appropriate completed IRS IRS W8 / W9 form.

Note, to digitally sign a W8 or W9, the document must be saved to your device, and opened using Adobe. Otherwise, the signature feature will not work properly.

If you are processing this on a Smart Phone or Tablet, and would like assistance on how to digitally sign a W8 / W9 on your device, Please see our Instructions for New Supplier Request via Smartphone page for informationon how to download PDF writer in order to prepare and sign a PDF document.

Fields with asterisks (*) are required.

Vendor / Payee Application – Businesses Only

Legal name of company or business *

Company “commonly known as” Name, if different from above, i.e. DBA

Please indicate the Wayne State person that invited you to conduct business with the University. *

Please provide the above person's e-mail address so we may notify them *

Corporate Sales / Mailing Address:

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Company Contact Name

Your E-Mail Address *

Email Address for us to send WSU Purchase Orders *

Phone *

Accounts Receivable / Remit To Address:

Same as mailing address, or

AR Address Line 1

AR Address Line 2

AR City

AR State

AR Zip

AR Country

AR Contact Name

AR Email Address

AR Phone

IRS W9 Form (signed)

You must provide a valid Federal Employer Identification Number (FEIN) in order for the University to process payment(s). The University is required by Federal law where applicable to report payments, along with the FEIN to Federal and State agencies. Failure to provide a correct name and Taxpayer Identification Number may subject your payments to a 28% federal income tax withholding. Additional withholding may apply for foreign entities. Payment Terms are Net 30, unless otherwise stated and agreed to by the University.

Attach your W8 or W9 Here *

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Enter your Federal Employer Identification Number (FEIN) *

Check appropriate box for federal tax classification (select only one) *

Business Details

Date Established

Approximate Number of Employees

Revenue for Last 3 Years (optional – used for classification as a Small Business)

Primary Commodities or Services Offered *

NAICS Code (s) - if known

DUNS Number - if known

Supplier Diversity Classification

Diverse businesses must be at least 51% owned and controlled by one or more individuals who are represented in the categories selected. Include a copy of your certificate(s) with this Application

Diversity Type: (select only one) *

Conflict of Interest:

Are you, or if this a business, are any Officer, Owner or Partner in this company an employee of Wayne State University, or have you been an employee within the past 24 month? *

Yes

Are any immediate family members or extended family members (e.g. spouse, child, sibling, parent, niece, nephew, or in-law) of any Officer, Owner or Partner employees of Wayne State University? *

Yes

Are there any other potential conflicts of interest in doing business with the University that we should be aware of? *

Yes

If yes to either above, please state who and explain and their University position or the family relationship (father, mother, sister, brother, child, etc.)

ACH Enrollment Form

If you would also like to Enroll in our Direct Deposit / ACH program, please complete the information below.

All fields in this section are required to successfully be entered in the Direct Deposit program, but are not required if you prefer to be paid by check.

Declaration:

I (we) hereby authorize Wayne State University (hereafter WSU) to initiate ACH automatic deposits (credits) to my account at the financial institution named below. Additionally, I authorize WSU to make necessary debit adjustments in the event a credit entry is made in error.

Further, I agree not to hold WSU responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or my institution or due to an error on the part of my financial institution in depositing funds into my (our) account. I will notify WSU immediately of any changes made to my checking account.

This agreement will remain in effect until WSU receives written notification of cancellation from me or my financial institution. Upon receipt of notice, I understand WSU will need 72 hours to comply with the request and interim deposits may occur.

ACH Payment Agreement Form Type

New Enrollment

Modify / Update Existing Enrollment

Vendor / Payee Banking Information:

Vendor / Payee Name (Name on the Account)

Name of Financial Institution

Branch/State

Routing Number *

Checking Account Number

ACH Remittance Advice Email

Vendor / Payee Authorization:

By checking this box and typing my name below, I acknowledge that the information provided is accurate and complete to the best of my knowledge.

I Agree

Typed Name: *

Date *