City of Westminster           Vendor Set-Up Form
                              To be filled out by Vendor ONLY

4800 West 92nd Avenue  *  Westminster, CO 80031  *  Phone 303-658-2400  *  Fax: 303-706-3923
Please fill out completely An incomplete form will create a delay in our payment(s) to you and your Payment(s) could be subject to the IRS required back-up withholding.

Name as it will appear on check



Do you use a DBA or acronym?



Remittance Address



Business Address



City, State,Zip



City, State,Zip



Accounts Receivable Contact



Phone Number / Fax Number



Vendor Type: (Check the appropriate box)
Corporation   Government Agency   Individual/Sole Proprietor   Non-Profit   Partnership

Will you provide medical services to the City of Westminster?
Will you provide legal services to the City of Westminster?
Will you provide services other than medical or legal?
Will you provide parts, supplies or materials to the City of Westminster?
Any special parent/subsidiary relationships?
If yes, please list ____________________________________________________________

Payment Terms


Discount Offered


Social Security # ________________________________or Federal TIN _______________________
NIGP Commodity Codes ______________________________________________________________

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.

Sign Here: Signature _________________________________   Date _____________________