Missouri State University

Vendor Registration Form

Payments will be made to this name

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Please include Contact Name, phone/fax/email of Contact for PO

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Mailing address for Checks and 1099 Reporting
Please include Name, phone/fax/email of remittance Contact

Do you currently have ACH capabilities?

RELATIONSHIP DISCLOSURE (Answer all):

[R1] Are you or any Officer, Director, Owner or Partner in this company an employee of Missouri State University
[R2] Is a direct family member of any of the above an employee of Missouri State University?
[R3] Does any University employee have an ownership interest in your firm?
[R4] Missouri State Alumni?

IRS Business Classification (must select one)

IRS Business Classification

(D)-Disregarded entity, (C)-Corporation, (P)-Partnership, (SP)-Sole Proprietor

Select if you maintain a regular place of business in the state of Missouri
Select Income Type, If Applicable:
Check all that apply: If certified, please send copy of certification to address below:

Substitute IRS Form W-9 Certification

Part 1: Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on page 1 to avoid backup withholding. For individuals, this is your Social Security Number (SSN). For Other Entities, it is your employer identification number (EIN) 

 

XXX-XX-XXXX
Or
    XX-XXXXXXX
    Part II: 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 because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

    3. I am a U.S. citizen or other U.S. Person (and authorized to sign an IRS form W-9)

    Certification instructions: You must notify us if item 2 above, if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement agreement (IRA), and generally, payments other than interest and dividends, you are required to sign the certification, but you must provide your correct TIN.

    For additional information refer to the IRS website link and go to Form W-9

     


    Office of Procurement Services

    901 South National Avenue,
    Carrington Hall 106, Springfield, MO-65897
    Phone: 417-836-5260
    Fax    : 417-836-6583

    Website: www.MissouriState.edu/Procurement

    If your business relationship is ONLY with the University's West Plains Campus:

    Business Services
    Missouri State University - West Plains
    128 Garfield, West Plains, MO-65775
    Phone: 417-255-7260
    fax    : 417-255-7259

    Website: www.wp.MissouriState.edu/BusinessServices