CITY OF VALLEJO

SUPPLIER PROFILE APPLICATION

(* Indicates Required Field)

* Company Name :		* Contact Name :
Email :		Fax :

	Business Address:		Remit To Address:
Street :		Street :
City :		City :
State :		State :
Zip :		Zip :
* Telephone :		* Telephone :

Federal Tax ID# or SSN :		City of Vallejo Business Lic # :
Type of Business : (Corp/LLP)		Terms :
Net Due/Days :		Discount % :
Will your company accept payment by EDI or Direct Deposit? :		Yes No
Bank Routing # :		Bank Account # :

Please indicate which products and/or services your company can supply by checking the appropriate box(s). Upon receipt of both the completed Supplier Mailing List Application and the completed Commodity/Class Listing, a detailed item list for each Commodity Category selected will be sent.

List any additional Commodities or Areas of Services not listed above :

THIS PROFILE MUST BE SIGNED BY AN OFFICER OF THE COMPANY

* Name :

Title :

Signature :

Date :