*Chugach Co. Name:
*Location:
*Phone:
Are you a:
Chugach Employee (only fill-in those areas with an asterisk ( * ).
Vendor (fill-out all portions of the form) or a
VENDOR'S QUESTIONNAIRE FORM
*Company Name (as shown on your income tax return):
*Doing Business As (name as shown on your invoice):
Business name/disregarded entity name, if different from above Company Name
*Remit Address:
*City:
Ordering Address:
*State:
City:
*Telephone #:
*Zip Code:
State:
Zip Code:
Fax #:
E-Mail Address:
Contact Name:
Payment Method & Terms:
CHECK
MASTERCARD/EPAYABLES
*
NET 30
2% NET 20
5% Net 15
Other
NET 25
2% NET 20
5% Net 15
Other
(see below)
Our MasterCard/EPayable program provides expedited cash receipts for vendors. Vendors will receive a remittance advice via email with
authorization to charge the MasterCard number provided.
*If choosing MASTERCARD/EPAYABLES, please fill out the additional enrollment form attached and return with VQ form.
Federal Tax Identification # (TIN):
–
*Social Security #:
–
CAGE Code:
–
9 digits: xx-xxxxxxx
9 digits: xxx-xx-xxxx
or
DUNS No + 4:
Supplier/Subcontractor General Product Line or Service:
NAICS Code(s):
- North American Industry Classification System (NAICS): See http://osha.gov/oshstats/naics-manual.html
Business Type: (check appropriate box for federal tax)
Sole Proprietorship
OWNER’S LEGAL NAME:
Corporation
C-Corp
Government Agency
City
State
Federal
Disregarded Entity
OWNER’S LEGAL NAME:
Partnership
OWNER’S LEGAL NAME:
LLC (Limited Liability Co.) Enter Tax Classification
C = C corporation
C
S
P
CAC-FIN-J010 / Rev. 11 / 12-13-12
Not for Profit Organization (please also check business type)
501(c)3 Corporation (Non-Profit)
S = S corporation P = partnership
Other Entities: See Note below
Foreign Owned
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S-Corp
1099 Type:
N/A
Medical
Rental
Misc Service
Legal
Business Size: (check ALL that apply) See http://www.sba.gov/size/indexguide.html for size standards.
Large
Small
Woman Owned
Minority Business
Veteran-Owned SB
CAC Shareholder
8(a) SBA
HUBZone
SB
Service-Disabled Veteran SB
Historically Black Colleges & Universities
Small Disadvantaged
African American
Hispanic American
Asian American
Subcontinent Asian American
Native American
Pacific Islander
Other _________________________________________________________
COMPANY REPRESENTATIVE CERTIFICATION
*Job Title:
*Printed Name:
*Signature:
*Date:
ACCTS. PAYABLE USE ONLY
Spoke With:
Contact Date:
A/P Tech:
Vendor #:
Certification: 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, and
3. I am a U.S. citizen or other U.S. person (defined on IRS Form W-9)
Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See IRS Form W-9 instructions on
page 4.
Notice: Under 15 U.S.C. 645(D), any person who misrepresents a firm's status as a Small Business Concern in order to obtain a contract to be awarded
under the preference programs established pursuant to Sections 8(a), 8(d), 9 or 15 of the Small Business Act or any other provision of Federal Law that
specifically references Section 8(d) for a definition of program eligibility, shall
(1) Be punished by imposition of fine, imprisonment, or both;
(2) Be subject to administrative remedies, including suspension and debarment; and
(3) Be ineligible of participation in programs conducted under the authority of the Act.
The small business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes
to furnish a product which it did not itself manufacture, is 500 employees. The size standard for products which it did manufacture and for all services, the
size standard is determined by NAICS Code.
Note: Other Entities: Enter your business name as shown on required federal tax documents on the “Name” line. This name should match the name shown
on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name” line.
CAC-FIN-J010 / Rev. 11 / 12-13-12
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Credit Card Acceptance Form
When you sign up, Chugach Alaska Corporation and its subsidiaries will provide you with a MasterCard payment
each time your invoices are due.
To: Vendor Enrollment
Fax number: 877-474-8066
Email: VendorSetup@chugach-ak.com
Enroll Us Now!
Enrollment Instructions:
To begin participating in our MasterCard payment program, please email the information as requested below and
include all fields in the body of the email. You can also complete and return this form by fax to the contact listed
above or call 1-907-563-8866 and ask for the Accounts Payable Department VMC Program.
Please print the information below.
Company Name:
Accounts Receivable Contact Information:
Name and Title:
Phone Number:
Remittance Email Address*:
*An e-mail address is required for the payment notification. We recommend a central email address, such as
accountsreceivable@vendorname.com.
We value your input! If you are not enrolling in our MasterCard Payment Program, please let us know why:

Do not currently accept MasterCard

Other (please explain below)
__________________________________________________________________________
___________________________________________________________________
CAC-FIN-J010 / Rev. 11 / 12-13-12
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