2. NAME (AS IT APPEARS ON YOUR INCOME TAX RETURN)*
   Please enter your company's legal name, or your name if you are an Individual/Sole Proprietor
4. BUSINESS NAME
   Please enter your company's business name/disregarded entity, if different from above
6. VENDOR TYPE*
   -- Select One --REGULARATTORNEYCOMPUTER SALESPRINTERREIMBURSEMENTRISK MANAGEMENTLAND ACQUISITIONDEATH BENEFITJURORCITY EMPLOYEE

   Please select one category that best describes you or your business
7. MBE, WBE, OR STATE CONTRACT HOLDER
   -- Select One --MINORITY BUSINESS ENTERPRISESTATE CONTRACTWOMAN BUSINESS ENTERPRISENOT APPLICABLE

   Please select if you or your business are a MBE, a WBE, or are the recepient of a Contract with the State of Indiana
11. ADDRESS
13. STREET NUMBER*
14. STREET NAME*
15. STREET TYPE*
17. APT, ROOM, OR SUITE #
18. PO BOX
20. CITY*
21. STATE*
22. ZIP*
26. REMIT TO ADDRESS
28. STREET NUMBER
29. STREET NAME
30. STREET TYPE
32. APT, ROOM OR SUITE #
33. PO BOX
35. CITY
36. STATE
37. ZIP
41. YOUR COMPANY'S CONTACT INFORMATION
43. CONTACTS FIRST NAME
44. CONTACTS LAST NAME
46. CONTACTS TITLE
    -- Select One --ACCOUNTS RECEIVABLEACCOUNT MANAGEROWNERCO-OWNERPARTS MANAGERSALES REPRESENTATIVE
47. PHONE
49. FAX NUMBER
    Please enter, if applicable
50. CONTACTS EMAIL ADDRESS*
52. ACCOUNTS RECEIVABLE EMAIL*
53. PURCHASE ORDER DELIVERY EMAIL*
55. WEBSITE
    Please enter your website, if applicable
59. ACH/EFT BANKING INFORMATION
61. ACH/EFT BANK NAME
62. ACH/EFT ROUTING NUMBER
63. ACH/EFT ACCOUNT #
65. BANK ACCOUNT TYPE
    -- Select One --CHECKINGSAVINGS
66. EMAIL ADDRESS
    Please enter the email address of the person you wish to be notified when a payment is sent
70. REQUESTING DEPARTMENT*
    Please enter the name of the City of Anderson department, or person, that requested this form to be filled out. If no one, please enter N/A
71. FREIGHT TERMS
    Please enter your terms, if applicable
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

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