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VENDOR'S QUESTIONNAIRE FORM
Payment Method & Terms:
CHECK NET 30 2% NET 20 5% Net 15 Other
MASTERCARD/EPAYABLES * NET 25 2% NET 20 5% Net 15 Other
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.
Business Type: (check appropriate box for federal tax)
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
Certification: Under Penalties of Perjury, I certify that:
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.
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: 907-563-3146
Enroll Us Now!
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.
Accounts Receivable Contact Information:
Name and Title:
Remittance Email Address*:
*An e-mail address is required for the payment notification. We recommend a central email address, such as firstname.lastname@example.org.
We value your input! If you are not enrolling in our MasterCard Payment Program, please let us know why:
CAC-FIN-J010 / Rev. 12 / 4-23-13 of
ОК. If you failed to fill out all the necessary fields, you will get corresponding message a message