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Get State Of Connecticut Agency Vendor Form

STATE OF CONNECTICUT - AGENCY VENDOR FORM Clear Form IMPORTANT ALL parts of this form must be completed signed and returned by the vendor. READ COMPLETE CAREFULLY COMPLETE VENDOR LEGAL BUSINESS NAME SP-26NB-IPDF Rev* 4/10 Taxpayer ID TIN SSN FEIN WRITE/TYPE SSN/FEIN NUMBER ABOVE BUSINESS NAME TRADE NAME DOING BUSINESS AS IF DIFFERENT FROM ABOVE BUSINESS ENTITY CORPORATION NON-PROFIT LLC PARTNERSHIP LLC SINGLE MEMBER ENTITY INDIVIDUAL/SOLE PROPRIETOR GOVERNMENT NOTE IF INDIVIDUAL/SOLE PROPRIETOR INDIVIDUAL S NAME AS OWNER MUST APPEAR IN THE LEGAL BUSINESS NAME BLOCK ABOVE* BUSINESS TYPE A. SALE OF COMMODITIES B. MEDICAL SERVICES C. ATTORNEY FEES D. RENTAL OF PROPERTY REAL ESTATE EQUIPMENT E* OTHER DESCRIBE IN DETAIL UNDER THIS TIN WHAT IS THE PRIMARY TYPE OF BUSINESS YOU PROVIDE TO THE STATE ENTER LETTER FROM ABOVE NOTE IF YOUR BUSINESS IS A PARTNERSHIP YOU MUST ATTACH THE NAMES AND TITLES OF ALL PARTNERS TO YOUR BID SUBMISSION* VENDOR ADDRESS STREET CITY STATE ZIP CODE Add Additional Business Address Contact information on back of this form* VENDOR E-MAIL ADDRESS VENDOR WEB SITE REMITTANCE INFORMATION INDICATE BELOW THE REMITTANCE ADDRESS OF YOUR BUSINESS* REMIT ADDRESS CONTACT INFORMATION NAME SAME AS VENDOR ADDRESS ABOVE* TYPE OR PRINT 1ST BUSINESS PHONE ND Ext. HOME PHONE 1ST PAGER CELLULAR 2ND PAGER 1ST FAX NUMBER TOLL FREE PHONE TELEX WRITTEN SIGNATURE OF PERSON AUTHORIZED TO SIGN PROPOSALS ON BEHALF OF THE ABOVE NAMED VENDOR DATE EXECUTED SIGN HERE TITLE OF AUTHORIZED PERSON IS YOUR BUSINESS CURRENTLY A DAS CERTIFIED SMALL BUSINESS ENTERPRISE YES ATTACH COPY OF CERTIFICATE YES NO IF YOU ARE A STATE EMPLOYEE INDICATE YOUR POSITION AGENCY AGENCY ADDRESS PURCHASE ORDER DISTRIBUTION E-MAIL ADDRESS NOTE THE E-MAIL ADDRESS INDICATED IMMEDIATELY ABOVE WILL BE USED TO FORWARD PURCHASE ORDERS TO YOUR BUSINESS* ADD FURTHER BUSINESS ADDRESS E-MAIL CONTACT INFORMATION ON SEPARATE SHEET IF REQUIRED. READ COMPLETE CAREFULLY COMPLETE VENDOR LEGAL BUSINESS NAME SP-26NB-IPDF Rev* 4/10 Taxpayer ID TIN SSN FEIN WRITE/TYPE SSN/FEIN NUMBER ABOVE BUSINESS NAME TRADE NAME DOING BUSINESS AS IF DIFFERENT FROM ABOVE BUSINESS ENTITY CORPORATION NON-PROFIT LLC PARTNERSHIP LLC SINGLE MEMBER ENTITY INDIVIDUAL/SOLE PROPRIETOR GOVERNMENT NOTE IF INDIVIDUAL/SOLE PROPRIETOR INDIVIDUAL S NAME AS OWNER MUST APPEAR IN THE LEGAL BUSINESS NAME BLOCK ABOVE* BUSINESS TYPE A. SALE OF COMMODITIES B. MEDICAL SERVICES C. ATTORNEY FEES D. RENTAL OF PROPERTY REAL ESTATE EQUIPMENT E* OTHER DESCRIBE IN DETAIL UNDER THIS TIN WHAT IS THE PRIMARY TYPE OF BUSINESS YOU PROVIDE TO THE STATE ENTER LETTER FROM ABOVE NOTE IF YOUR BUSINESS IS A PARTNERSHIP YOU MUST ATTACH THE NAMES AND TITLES OF ALL PARTNERS TO YOUR BID SUBMISSION* VENDOR ADDRESS STREET CITY STATE ZIP CODE Add Additional Business Address Contact information on back of this form* VENDOR E-MAIL ADDRESS VENDOR WEB SITE REMITTANCE INFORMATION INDICATE BELOW THE REMITTANCE ADDRESS OF YOUR BUSINESS* REMIT ADDRESS CONTACT INFORMATION NAME SAME AS VENDOR ADDRESS ABOVE* TYPE OR PRINT 1ST BUSINESS PHONE ND Ext.

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