"Vendor Management Form (Teamworks)" - Georgia (United States)

"Vendor Management Form (Teamworks)" - Georgia (United States) Download Pdf
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Vendor Management Form (Teamworks) is a legal document that was released by the Georgia Department of Community Health - a government authority operating within Georgia (United States).

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VENDOR MANAGEMENT FORM (TeamWorks)
The initiating Agency will submit this form to the Vendor Management Group for verification and approval. Agency must
complete section 5 of the form to obtain approval.
SECTION 1 – VENDOR IDENTIFICATION (COMPLETE ALL APPLICABLE FIELDS)
VENDOR NUMBER: _________________________________ ____
FEI/SSN/EMP ID NUMBER:________________________________
VENDOR NAME: _______________________________________________________________________________________________
PAYMENT ALT NAME: (IF CHECK IS TO BE PAYABLE IN A DIFFERENT NAME) ________________________________________________
ADDRESS:_____________________________________________________________________________________________________
CITY: ________________________________STATE:__________________ZIP CODE: __________________ COUNTRY:______________
PHONE NUMBER: ________________________________________FAX NUMBER: ___________________________________________
CONTACT EMAIL: ________________________________________________________________________________________________
PYMT REMIT EMAIL
____
____________________________________________________LOC #_________________________
PYMT REMIT EMAIL
____________________________________________________LOC #_________________________
SECTION 2 – BANK ACCOUNT INFORMATION (ATTACH COPY OF VOIDED CHECK)
ROUTING #_________________________________ BANK ACCOUNT #____________________________________
Check here if General Bank Account can be used by ALL State of Georgia agencies making payments
Check here if this account can only be used for a SPECIFIC purpose_________________________________________
(
(Indicate specific purpose for which this account can be used)
I authorize the State of Georgia to deposit payment for goods or services received into the provided bank account by the Automated Clearing House (ACH). I further
acknowledge that this agreement is to remain in full effect until such time as changes to the bank account information are submitted in writing by the vendor or individual
named above. I understand it is the sole responsibility of the vendor or individual to notify the State of Georgia of any changes to the bank account information.
_______________________________________
_______________________________________
_________
(Vendor Printed Name)
(Vendor Signature)
(Date)
SECTION 3 – SPECIFY TYPE OF ACTION (CHECK ALL THAT APPLY)
☐ New Vendor
☐ E-Payable
☐ 1099 Code____________________
☐ Classification Change ___________________
☐ Add address
☐ FEI/TIN Change**
☐ Name Change**
☐ Change of Address: Address #___________
☐ Other (provide details in Section 4)
☐ Bank Account Add
☐ Bank Account Change
☐ Bank Account Delete
Documentation for Vendor Name/TIN changes must include at least one of the following: IRS documentation (tax documents, FEI issuance letter, etc);
Confirmation from Secretary of State’s office of legal name change OR a newly completed W-9 form provided by the vendor.
SIC CODES (CHECK ALL THAT APPLY)
Small Business
Women Owned
Minority Business Enterprise
African American
☐ Asian American
☐
☐
☐
☐
GA Based Business
Minority Business Certified
Hispanic-Latino
Native American
☐ Pacific Islander
☐
☐
☐
☐
SECTION 4 – ADDITIONAL COMMENTS
SECTION 5 – STATE OF GEORGIA AGENCY CONTACT INFORMATION (OFFICE USE ONLY)
By my signature, I certify that all reasonable effort has been made to submit information that is accurate, true, and is
associated with the vendor name and Tax ID listed above.
Requestor Name: ____________________________________________Agency BU#:____________Date:__________________
Signature: _______________________________________________________________________________________________
Email: ______________________________________________Phone:_____________________Fax #: _____________________
VENDOR MANAGEMENT FORM (TeamWorks)
The initiating Agency will submit this form to the Vendor Management Group for verification and approval. Agency must
complete section 5 of the form to obtain approval.
SECTION 1 – VENDOR IDENTIFICATION (COMPLETE ALL APPLICABLE FIELDS)
VENDOR NUMBER: _________________________________ ____
FEI/SSN/EMP ID NUMBER:________________________________
VENDOR NAME: _______________________________________________________________________________________________
PAYMENT ALT NAME: (IF CHECK IS TO BE PAYABLE IN A DIFFERENT NAME) ________________________________________________
ADDRESS:_____________________________________________________________________________________________________
CITY: ________________________________STATE:__________________ZIP CODE: __________________ COUNTRY:______________
PHONE NUMBER: ________________________________________FAX NUMBER: ___________________________________________
CONTACT EMAIL: ________________________________________________________________________________________________
PYMT REMIT EMAIL
____
____________________________________________________LOC #_________________________
PYMT REMIT EMAIL
____________________________________________________LOC #_________________________
SECTION 2 – BANK ACCOUNT INFORMATION (ATTACH COPY OF VOIDED CHECK)
ROUTING #_________________________________ BANK ACCOUNT #____________________________________
Check here if General Bank Account can be used by ALL State of Georgia agencies making payments
Check here if this account can only be used for a SPECIFIC purpose_________________________________________
(
(Indicate specific purpose for which this account can be used)
I authorize the State of Georgia to deposit payment for goods or services received into the provided bank account by the Automated Clearing House (ACH). I further
acknowledge that this agreement is to remain in full effect until such time as changes to the bank account information are submitted in writing by the vendor or individual
named above. I understand it is the sole responsibility of the vendor or individual to notify the State of Georgia of any changes to the bank account information.
_______________________________________
_______________________________________
_________
(Vendor Printed Name)
(Vendor Signature)
(Date)
SECTION 3 – SPECIFY TYPE OF ACTION (CHECK ALL THAT APPLY)
☐ New Vendor
☐ E-Payable
☐ 1099 Code____________________
☐ Classification Change ___________________
☐ Add address
☐ FEI/TIN Change**
☐ Name Change**
☐ Change of Address: Address #___________
☐ Other (provide details in Section 4)
☐ Bank Account Add
☐ Bank Account Change
☐ Bank Account Delete
Documentation for Vendor Name/TIN changes must include at least one of the following: IRS documentation (tax documents, FEI issuance letter, etc);
Confirmation from Secretary of State’s office of legal name change OR a newly completed W-9 form provided by the vendor.
SIC CODES (CHECK ALL THAT APPLY)
Small Business
Women Owned
Minority Business Enterprise
African American
☐ Asian American
☐
☐
☐
☐
GA Based Business
Minority Business Certified
Hispanic-Latino
Native American
☐ Pacific Islander
☐
☐
☐
☐
SECTION 4 – ADDITIONAL COMMENTS
SECTION 5 – STATE OF GEORGIA AGENCY CONTACT INFORMATION (OFFICE USE ONLY)
By my signature, I certify that all reasonable effort has been made to submit information that is accurate, true, and is
associated with the vendor name and Tax ID listed above.
Requestor Name: ____________________________________________Agency BU#:____________Date:__________________
Signature: _______________________________________________________________________________________________
Email: ______________________________________________Phone:_____________________Fax #: _____________________
Georgia Department of Community Health Georgia (United States) Legal Forms United States Legal Forms

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