Supplier Setup Request Form
Instructions/Purpose: This form is used to setup a new supplier or change information for an existing supplier. The completed form and a copy of the W-9 or W-8 must be forwarded to Purchasing via email to or faxed to 920-766-8711.
Supplier Information: (check facilities this applies to):Kaukauna DePere Mosinee Old Town Rhinelander
Supplier Name (Order to): / Federal ID or Tax ID #: (REQUIRED)
Supplier Address: / Supplier Email Address:
City: / State: / Province: / County: / Zip: / Country:
Supplier Phone Number: / Supplier Fax Number: / Contact Name: / Contact Phone Number:
Off-Hours Contact Name with Phone Number: (provide 2 if possible)
1)
2)
Preferred method of receiving Purchase Orders: Fax or Email Please check a box
Fax # : Email Address:
Banking Information (fill out Bank information, if you want to be paid by ACH) PREFERRED
Bank Name: / Routing #: / Banking #:
Bank Address:
Organization Type: (you MUST choose one of the following):
Individual Government Agency
Partnership/LLP/LLC Non Profit
Corporation
Foreign Government Agency
Foreign Corporation/Partnership
Foreign Individual / Minority Status:
Minority Certified Not Certified
Women-Owned Asian-Pacific
Veteran Disabled/Other
Hispanic Asian-Indian
African American
Certificate must be attached
Remittance address if different from above: / Supplier Name: / Supplier Address:
Telephone Number:
Fax Number: / Email Address for ACH Remittance:
Internal Use Only
CDC Vendor Yes No Fiber Certification ______
Outsource Vendor Yes No If yes, initiate Outsource Procedure Agreement
Name of Person Submitting Request: / Request Date
Reason for Request (if applicable): ____Add New Supplier ____Update Existing Supplier (give reason why) ____ Check Request
Supplier Terms (Required): / Payment Terms:
NET 45 DAYS / Freight Code:
Approved By: Date:
Vendor Number Assigned:
Raw Material Supplier Requirements sent / Non-Disclosure Agreement signed with Supplier
Certificate of Insurance on file for Supplier / Updated MSDS forms on file for Supplier
M:\Sourcing\Forms\Expera Forms\Expera Supplier Setup Request Form.doc