Vendor Intake Form

Company Name

Vendor ID (if applicable)

Alternate Name

Tax ID Number (FEIN or SSN)

Point of Contact Name

Title

Vendor Address

Payment Address (if different from above)

Phone

Fax

Vendor Email

Tax Exempt?

Yes No

Vendor Website

Organization Type

Separate Checks

Yes No

Except Purchasing Cards ? (ex. Visa, MC

Yes No

Banking Information

Routing Number

Requestor / Vendor's Name

Agreement

I hereby certify that the facts set forth in the above vendor application are true and complete to the best of my knowledge. I authorize RCM Utilities, LLC to verify the accuracy of this information. I release RCM Utilities, LLC from any and all liability that could result from obtaining and making decisions based on such information. I will adhere to all RCM Utilities, LLC policies, rules, and regulations. I further understand that these policies, rules, and regulations do not constitute the terms of an implied agreement.

Signature

Date

Vendor Intake Form

Vendor Intake Form

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