Vendor Application Intel System Barebone SC5650HCBRPRNA Fa Pds Ufva

User Manual: Intel System Barebone SC5650HCBRPRNA

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FA-PDS-UFVA 03/2010

Vendor Application - University of Florida

You may fill these forms out on-line, print them, and send them by mail, fax or email to Vendor Maintenance:

Mail: University of Florida, Attn: Vendor Maintenance, PO Box 115350, Gainesville, FL, 32611-5350

Fax: Attn: Vendor Maintenance at 352-392-0081

Email: addvendor@ufl.edu (use this address if you need assistance with these forms)

Note: This application is valid for one year from last payment or application date, whichever is later.

A W-9 must be attached to process this application.

Name of Business or Payee Date of Application

Part 1 – Contact Information

Main Address

Remit Address

City

City

State

Zip

State

Zip

Part 2 – Small and/or Minority Status Information – Check all that apply

FEDERAL

CLASSIFICATIONS

STATE OF FLORIDA CERTIFIED

MINORITY BUSINESS

ENTERPRISES (CMBE)

NON-CERTIFIED

MINORITY BUSINESS

ENTERPRISES (NMBE)

NON-PROFIT ORGANIZATION

 SBA 8(a) Certification

 African American

 African American

 Minority Board of Directors

 Small Disadvantaged

Business Certification  Hispanic  Hispanic  Minority Employees

 HUBZone Certification

 Asian/Hawaiian

 Asian/Hawaiian

 Minority Community Served

 Veteran

 Native American

 Native American

 Other Non-Profit



Service Disabled Veteran



American Woman



American Woman

 Vietnam Veteran

Check all that apply

 Women Owned

 Minority-Owned Business

A. If you select a classification that is certified by a Federal or State agency, please supply your certification numbers and expiration

dates for each certification and the agencies along with this application.

B. To determine your Federal Size Standard, please access the U.S. Small Business Administration’s web site

(http://www.sba.gov/smallbusinessplanner/) or the SBA’s Size Standards web site (http://www.sba.gov/size/) to look up your North

American Industry Classification System (NAICS) Code and the qualifying number of employee’s or annual dollar amount.

If you are using Federal Size Standards, please specify the codes used:

NAICS CODE: Number of Employees: OR Annual Amount: $

Part 3 – Purchase Order and Payment Preferences

By which delivery method do you prefer to receive purchase orders?

 Fax

 Email

Payment Discount Terms:

 2% Net 10

 Other: ___________________________

By which delivery method do you prefer to receive payment?

 Check

 EFT (To receive payment by Electronic Funds Transfer, please complete the attached form and submit to the address)

 VISA ePayables (You will be contacted by University Disbursement Services staff)

Part 4 – Additional Payment Information and Signature

I certify that the information supplied herein is correct to the best of my knowledge.

Name of Person Completing/Authorizing Application Title of Person Completing/Authorizing Application

Signature of Person Completing/Authorizing Application Date

Business Phone Number

Contact Person

Business Fax Number

Contact Phone Number

(if different from business number)

Business Website

Contact Email

Remit Address

City

State

Zip

Vendor Application - University of Florida

You may fill these forms out on-line, print them, and send them by mail, fax or email to Vendor Maintenance:

Mail: University of Florida, Attn: Vendor Maintenance, PO Box 115350, Gainesville, FL, 32611-5350

Fax: Attn: Vendor Maintenance at 352-392-0081

Email: addvendor@ufl.edu (use this address if you need assistance with these forms)

Note: This application is valid for one year from last payment or application date, whichever is later.

A W-9 must be attached to process this application.

Name of Business or Payee Date of Application

Part 1 – Contact Information

Main Address

City

State

Zip

Business Phone Number Contact Person

Business Fax Number Contact Phone Number

(if different from business number)

Business Website Contact Email

Part 2 – Small and/or Minority Status Information – Check all that apply

FEDERAL

CLASSIFICATIONS

STATE OF FLORIDA CERTIFIED

MINORITY BUSINESS

ENTERPRISES (CMBE)

NON-CERTIFIED

MINORITY BUSINESS

ENTERPRISES (NMBE)

NON-PROFIT ORGANIZATION



SBA 8(a) Certification



African American



African American



Minority Board of Directors

 Small Disadvantaged

Business Certification

 Hispanic

 Hispanic

 Minority Employees

 HUBZone Certification

 Asian/Hawaiian

 Asian/Hawaiian

 Minority Community Served

 Veteran

 Native American

 Native American

 Other Non-Profit

 Service Disabled Veteran

 American Woman

 American Woman

 Vietnam Veteran

Check all that apply

 Women Owned

 Minority-Owned Business

A. If you select a classification that is certified by a Federal or State agency, please supply your certification numbers and expiration

dates for each certification and the agencies along with this application.

B. To determine your Federal Size Standard, please access the U.S. Small Business Administration’s web site

(http://www.sba.gov/smallbusinessplanner/) or the SBA’s Size Standards web site (http://www.sba.gov/size/) to look up your North

American Industry Classification System (NAICS) Code and the qualifying number of employee’s or annual dollar amount.

If you are using Federal Size Standards, please specify the codes used:

NAICS CODE: Number of Employees: OR Annual Amount: $

Part 3 – Purchase Order and Payment Preferences

By which delivery method do you prefer to receive purchase orders?

 Fax

 Email

Payment Discount Terms:

 2% Net 10

 Other:

By which delivery method do you prefer to receive payment?

 Check

 EFT (To receive payment by Electronic Funds Transfer, please complete the attached form and submit to the address)

 VISA ePayables (You will be contacted by University Disbursement Services staff)

Part 4 – Additional Payment Information and Signature

I certify that the information supplied herein is correct to the best of my knowledge.

Name of Person Completing/Authorizing Application Title of Person Completing/Authorizing Application

Signature of Person Completing/Authorizing Application Date

Please leave this area blank

PLEASE READ AND CAREFULLY FOLLOW INSTRUCTIONS!

For a Start or Change of electronic payment all

boxes

must be

completed.

Do not leave

information blank!

This form will start, change, or stop electronic payment for

all payments received by you from the University of Florida.

This does not apply to employee salary payments.

Name:

Please be sure your last name on this form matches the last

name on the W-9 on file with Purchasing and Disbursement

Services Office. Your electronic payment will not start if the last

names do not match.

Action Requested:

(1) Check Start if you don't have electronic payments and wish to.

(2) Check Change if you have electronic payments and wish to

change your financial institution or just your account

number or account type (checking or savings). Your

current electronic payment is stopped when a change

request is received. While the change is being processed,

you will be paid by

warrant

(check).

(3) Check Stop if you wish to stop your electronic payment.

(4) Check Name Change Only if you are changing only your

name to correspond to your W-9. Complete the top portion

of the form and sign and date it.

Account Number:

Please make sure the account number written on this form is

correct. If you are not sure, PLEASE CONTACT YOUR

FINANCIAL INSTITUTION.

Transit Routing Number:

This is the nine-digit number that identifies your financial institution.

It is found in the bottom left-hand corner of your checks.

AGREEMENT

I hereby authorize and request the University of Florida to initiate

credit entries and, if necessary, a debit entry in accordance with

NACHA rules reversing a credit entry made in error, to my account

at the financial institution named. The electronic payment data

remains in effect until withdrawn by:

(a) Written notification to the University;

(b) death or legal incapacity;

(c) the financial institution or

(d) the University of Florida.

Special Note:

Please make sure your electronic payment has stopped before

closing your account. Otherwise, the funds will be returned to the

University and cause a delay before you receive your payment in

the mail.

Please note that in order to add your EFT information we must

have one of the three forms of back up:

1). A voided check which confirms the account/routing number

on your form.

2). A signed letter from a bank representative on bank letter

head which lists and confirms the account/routing number

3). A signed letter from the company's CFO/owner on company

letter head which lists and confirms the account/routing number.

Please return completed form with a voided

check attached to:

Fax:

352-

3

92-0081

E-mail:

addvendor@ufl.edu

UNIVERSITY OF FLORIDA

ELECTRONIC

PAYMENT AUTHORIZATION Michael

V.

McKee, University Controller PLEASE

TYPE

OR PRINT

CLEARLY

Your Tax Identification Number

Legal Name

Address (Number,

Street)

City

State Zip Code

Telephone

( )

Fax

( )

Action Requested

(Check Only

One)

(1)

Start

(2)

Change

(3)

Stop

(4)

Name Change Only

Account

Type

(Check Only one)

(1)

Checking

(2)

Savings

Your Account

Number

Transit Routing Number of Your Financial Institution

Name of Your Financial Institution

Telephone Number of Your Financial Institution

( )

Signature Date

Email address for Remittance Advice

THIS FORM MUST BE SIGNED AND DATED BY PAYEE

Signature

above signifies acceptance of the terms and conditions in

the

AGREEMENT

to the

right.

Or mail

to:

University of

Florida

ATTN: Vendor

Maintenance

PO Box

115350

Gainesville, FL 32611-5350

Telephone: (352) 392-1241

FA-PDS-UFVA

01/2015