SUPPLER INFORMATION / SETUP FORM

ATTENTION: Please COMPLETE and Email to Ultra Electronics –3Phoenix Purchasing office or Fax: (703)956-6481.

If you have any Questions, CALL (703)956-6480 (Purchasing Department).

Ultra Electronics –3Phoenix Internal Use Only:
Supplier Number:
Add New Supplier: / Requested by:
Activate / Change: / Date Requested:
Credit Card / NET Terms: / Click to Select from ListCredit CardNET TermsCC and NET Terms / Evaluation Request #:
Attention:Please complete this section in full, do not abbreviate.
Supplier / General
Supplier Name: / Division of (if applicable): / DUNS No.:
Tax ID # (TIN): / CAGE Code No.: / NAICS Code(s):
Delivery Terms: / Payment Terms: / Default Ship Via:
General Information
Address: / PO Box: / Suite:
City: / State: / ZIP + 4: / Country:
Point of Contact: / Telephone Number (800 #’s preferred): / Fax #:
Web Address: / E-Mail Address:
Quality Rep.: / Business Type: / Click to Select from ListConstructionManufacturingReps and DistributorsResearch and DevelopmentService
Type of Product / Service Provided:
Payment Address Information (if different than address above)
Address: / PO Box: / Suite:
City: / State: / ZIP + 4: / Country:
Accounting POC: / Telephone Number (800 #’s preferred): / Fax #:
E-Mail Address:
AR POC: / Telephone Number (800 #’s preferred): / Fax #:
E-Mail Address:
Order Address Information (if different than address above)
Address: / PO Box: / Suite:
City: / State: / ZIP + 4: / Country:
Point of Contact: / Telephone Number (800 #’s preferred): / Fax #:
E-Mail Address:
Classification – Please check all applicable boxes and select specific classifications from drop down selections below:
Foreign Company: / Veteran Owned: / HUB Zone: / Select from appropriate dropdown box below:
Large Business: / Woman Owned: / Service Disabled Veteran: / Select Women-Owned DescriptionAmerican Indian/Alaskan FemaleAsian FemaleBlack FemaleCaucasian/White FemaleFilipino FemaleHispanic FemalePolynesian Female
Small Business: / Small Disadvantaged: / Publicly Owned: / Select Male DescriptionAsian MaleAmerican Indian/Alaskan MaleBlack MaleCaucasian/White MaleFilipino MaleHispanic MalePolynesian Male
Minority Owned:
Certification– Please check all applicable boxes and fill in relevant information:
ISO Certified: / ISO- / Cert. # (Attach Copy): / Expiration Date:
ISO- / Cert. # (Attach Copy): / Expiration Date:
Other Certification: / Cert. # (Attach Copy): / Expiration Date:
Other Certification: / Cert. # (Attach Copy): / Expiration Date:

PC-FM-027; Rev 2

Form Effective Date: 29October 2015