Vendor Application Form

Street Address (Physical)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business License Number*
If no business license number, indicate "none"
City/State*
State Contractor's Number
Class
State
Type of Organization*

IndividualPartnershipCorporationTrust/Estate/Charitable OrganizationSole ProprietorGovernmental Entity
Is your organization tax exempt under IRS Code Section 501(a)?*

YesNo

Mailing Address for Bids/Proposals

Please note: All notices are posted at www.danvilleva.gov/bids and in the Purchasing Office.
Be sure to sign up for notifications at www.danvilleva.gov/notify.
I prefer to receive Bids/Proposals via Email instead of regular mail*

YesNo
Mailing Address (if different from physical address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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, either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service (IRS) has notified me that I am no longer subject to backup withholding.
You must cross out item (2.) above if you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. (See specific instructions on IRS Form W-9).
Contact Person (printed or typed)*
Date*

MonthDayYear
Date
Signature*

Clear
Please provide a Form W-9 with this completed Vendor Application Form.*

Cancelof

Submittal Options: