PROCUREMENT & CONTRACTS
Procurement & Contracts
PROCUREMENT & CONTRACTS VDIM
Foreign Entity / Individual Supplier Information Form
Purpose: Information contained in this form will be used by UC San Diego to collect supplier information. You must
complete this form in order to be added to our supplier database.
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To avoid processing delays, please properly complete the form. Improperly completed forms will be returned to
the supplier to resubmit.
Please read the instructions before completing the form.
Fields marked * are required for submission.
Supplier Name
Person or Sole First Name:
Proprietor *
(as shown on your income
tax return)
Last Name:
or
Business Name or DBA
*
(if different from above)
Supplier Info
Supplier Type *
Click the appropriate circle
Non-Resident Alien (person permanently residing in a country other than the US)
Foreign Entity with U.S. Presence (business with a US Tax)
Foreign Entity (business with no US tax ID)
Will you be performing
services in the US? *
Yes
No
If yes, describe type of service to be performed:
U.S. Taxpayer Identification Number
Employer's
Identification Number Leave blank if you do not have one
(EIN),
Social security Number
(SSN), or
IRS Individual
Taxpayer Identification
Number (ITIN)
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Purchase Order Mailing Address
Street Address/ Suite *
City or Town*
Province, State or
County *
Postal Code *
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Country *
Email POs To *
UCSD preferred method
or
Fax POs To
Employee-Supplier Relationship status
Employee-Supplier
Relationship *
UCSD Employee
Former UCSD Employee
Relative of a UCSD Employee
Click the appropriate circle
Relationship --Choose One--
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UC Employee (Non-UCSD)
Campus --Choose One-Relative of a UC Employee (Non-UCSD)
Relationship --Choose One-UC Retiree
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No Relationship:
Supplier affirms that to the best of his/her knowledge there exists no actual or potential conflict of interest
between Contractor's family, business or financial interests and UCSD. In the event of change in
Contractor's private interest that has potential for conflict of interest, Contractor will promptly notify UCSD.
If a employee-supplier relationship exists, you must complete the disclosure form and provide to the
requesting department.
Dun & Bradstreet
DUNS # *
Foreign entities can register
for a DUNS number for free.
For more information:
www.dnb.com
or
I do not have a DUNS number. *
Type of Business
Primary Type of
Business *
Click the appropriate circle
Manufacturer
Distributor
Dealer
Retail
Service
Manufacturer's Agent
Broker
Fabricator
Wholesaler
Other
If Other, please describe.
Primary Commodities *
Select up to 3 commodities.
--Choose One---Choose One---Choose One--
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NAICS Code(s)
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North American Industry
Classification System Code
Lookup code: http://www.census.gov/eos/www/naics
Description of
products and services
*
Business Website
Company Web Page
URL
Remit Payment Information
Same as purchase order mailing address
Make Payments
Payable To *
Street Address/ Suite *
City or Town *
Province,State or
County *
Postal Code *
Country *
UCSD's preferred method of payment is through our Procurement card program or Direct Deposit. Please indicate if
you accept either or both:
Credit Card Payment
Direct Deposit View instructions:http://www-bfs.ucsd.edu/dis/pdf/Disb_Dir_Dep.pdf
Accounts Receivable Contact Information
Same as Individual/Sole Proprietor listed in Section I
Accounts Receivable
(A/R) Contact *
A/R Contact Phone *
A/R Contact E-Mail *
Sales and Customer Service Contact Information
Same as Individual/Sole Proprietor listed in Section I
Sales Representative
Sales Contact Phone
Sales Contact E-Mail
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Customer Service
Contact Phone *
Customer Service
Contact Fax
Customer Service
Contact E-Mail
Insurance Information
Do you have
insurance? *
Yes
No
If yes, please send an electronic copy of your ACORD (Insurance Certificate) to UC@instracking.com. Include company name in the
subject line or body of the message with attachment.
For Policy and insurance limits review this link: UC Terms and Conditions of Purchase
Persons Authorized to Commit Your Firm to a Contract
Same as Individual/Sole Proprietor listed in Section I
Name
Job Title
E-mail
Phone
Certification
By submitting this form, you are providing your electronic signature and certifying that the information
provided in this form is true and correct. If any of the information on this form changes, you will be
responsible for advising UCSD Procurement & Contracts.
UCSD may request completion of additional forms based on your foreign status such as IRS W-8BEN-E, W8ECI, or W-8EXP forms.
Authorized Supplier's Representative Completing Form
Same as Individual/Sole Proprietor listed in Section I
Submitted By *
Job Title *
Contact Phone Number
*
Contact email *
If your Submission transfers successfully, you will receive a Confirmation immediately upon completion.You may choose
to screen print the Confirmation for your records.
Submit
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Procurement & Contracts Department
University of California, San Diego
9500 Gilman Drive MC 0914
La Jolla, CA 92093-0914
Phone: 858-534-9494
Fax: 858-534-5803
UC San Diego 9500 Gilman Dr. La Jolla, CA 92093 (858) 534-2230
Copyright 2008 Regents of the University of California. All rights reserved.
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