Eastern Kentucky University requires a Federal Tax Identification number or Social Security number for all vendors or persons doing business with the University in order to comply with Federal Regulations and tax reporting requirements. Please take a few minutes to fill out this information and return to us to ensure prompt payment of your invoices. Thank you for the valuable service you have provided Eastern Kentucky University, and we look forward to a long and lasting relationship. IF SENDING A W-9, PLEASE RETURN THIS FORM ALSO.

For your convenience, you may return the information one of the following ways:

FAX: Vendor File @ 859-622-2047 Mail:

Purchasing Division Eastern Kentucky University Commonwealth 14th Floor #1411 521 Lancaster Avenue Richmond, Kentucky 40475 Phone # (859)622-2246

EMAIL: adm.purchasing@eku.edu

Please type or print legibly

Please type or print legibly VENDOR INFORMATION

VENDOR INFORMATION

Name of Firm * (Company or Individual) Phone Number * Make Checks Payable To *

Address * Fax Number * Payment Address *

Address Web Site Address or E-mail Payment Address

Address Vendor Representative Name on Invoice *

City * State * Zip* Federal Tax ID Number ** Social Security Number **

Willing to accept ACH payments * Yes ☐ No ☐ Bank Name & Routing # ____________________ Bank Account # ____________________ Willing to accept credit card payments* Yes ☐ No ☐ Payment Terms *

• * required fields **Federal Tax ID Number- This field must be completed if “Name of Firm” is a company name.

**Federal Tax ID Number- This field must be completed if “Name of Firm” is a company name.

Social Security Number- This field must be completed if “Name of Firm” is an individual’s name.

*REGISTRATION

Any foreign corporation (outside the State of Kentucky) must obtain a certificate of authority from the Secretary of State as is required by KRS 271B.15-010 KRS 14A.9-010-14A.9-090 https://secure.kentucky.gov/sos/ftbr/Welcome.aspx

• Certificate #: ___
• Claimed exemption:

Any “person” (business or individual) making retail sales in the state are to be registered to collect Kentucky sales and use tax. If the foreign individual (or business) is making retail sales they should be registered for Kentucky sales and use tax purposes by completing a Tax Registration Application (form 10A100).

• Consumer Use Tax Account number: ___
• Sales Tax Account Number: ___

CERTIFICATION

Under penalties of perjury. I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me) and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U. S. person (including a U.S. resident alien).

Cervicalion instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholdings because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct Taxpayer Identification Number.

Signature of U.S. Person ___ Date ___

Date ___

Type of Ownership (Check Appropriate Box(es))* Business Classification (Check Appropriate Box(es))*

☐ (01) Individual/Sole Proprietorship ☐ (02) Partnership ☐ (03) Corporation-Incorporated in (State) ☐ (04) Non-profit/Education ☐ (05) Non-Resident Alien ☐ (06) Exempt from backup withholding ☐ Other: ____________ ☐ (SM) Small Business ☐ (LG) Large Business ☐ (CT) In County ☐ (MN) Minority Owned ☐ (WO) Women Owned ☐ (SD) Small Disadvantaged Business ☐ (GA) Government Agency ☐ (NP) Non-Profit ☐ (AL) Alumni Owned ☐ (HZ) Hub Zone Small Business ☐ Other (Specify) ____________

*Business Classification Reference Links: www.ccr.gov/sizestandard.asp, https://eweb1.sba.gov/hubzone/internet/general/whoweare.cfm, and http://app1.sba.gov/faqs/fagindex.cfm?areaID=11

p://app1.sba.gov/faqs/faqindex.cfm?areaID=11

rinted Name of Authorizing Official: ___

Social: ___ Authorized Signature: ___

Date: _____