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

	YES	NO
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 _____________________