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

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).

Form Details:

The latest edition currently provided by the Georgia Department of Community Health;
Ready to use and print;
Easy to customize;
Compatible with most PDF-viewing applications;
Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Community Health.

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

Download PDF

Fill PDF online

Rate (4.8 / 5) 52 votes

Show Pagination

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**