HaShems Harvest

Vendor Data Sheet & Application

GENERAL INFORMATION:

 

  1. Firm or Business Name:

      

  1. Doing Business As (DBA):

 

  1. Street Address: 

 

      4.  Billing Address:

 

  1. City:

 

       5a. State

 

       5b.  Zip:

 

  1. Telephone:

 

       7. Fax:

 

  1. Please list all offices and/or affiliate addresses below:

      

 

      8c.

 

  1. E-Mail Address:

 

       10. Accounts Payable Contact Name:

 

       11. Years in Business:

 

       12. Federal Tax Number:

 

       13. Type of Business:            Sole Proprietorship           Corporation                     Partnership                                 Subsidiary

 

       14. Type of work:

 

       15. Proprietor, Partners, Officers, if incorporated:

 

       15a. Name:

 

      Home Address:

 

      City:

 

     State:

 

      Zip Code:

 

      SS#:

 

      15 b. Name:

 

      Home Address:

 

     City:

  

    State:

 

    Zip Code:

 

    SS#:

 

   16. Year Business Established:

 

   17. At Present Location Since?

  

   18. List employee(s) names and titles that can sign contracts and/or authorize purchase orders/work orders on behalf             of your company:                              

     2.

 

    3.

 

    19. Are you accredited by the Dunn & Bradstreet and/or the Better Business Bureau?           Yes   /            No

          CREDIT REFERENCES: (Please provide three)

 

         Company Name:

 

 

          Mailing Address:

 

 

        Telephone Number:

   

        Fax Number:

 

        Contact Person:

 

        Title:

 

       E-Mail Address:

 

       How Long Have You Been Doing Business With This Company?

 

CREDIT REFERENCES: (Please provide three)

 

  1. Company Name:

 

 

 

Mailing Address:

 

 

 

Telephone Number:

 

 

 

Fax Number:

 

 

 

Contact Person:

 

 

 

Title:

 

 

 

E-Mail Address:

 

 

 

How Long Have You Been Doing Business With This Company?

 

 

 

 

CREDIT REFERENCES: (Please provide three)

 

  1. Company Name:

 

 

 

Mailing Address:

 

 

 

Telephone Number:

 

 

 

Fax Number:

 

 

 

Contact Person:

 

 

 

Title:

 

 

 

E-Mail Address:

 

 

 

How Long Have You Been Doing Business With This Company?

 

 

 

 

 

AUTHORIZATION FOR RELEASE OF INFORMATION:

 

I hereby warrant that the above information is true and correct, and is furnished for the purpose of establishing a vendor relationship with Hashems Harvest.  I hereby agree that Hashems Harvest may investigate my record and that, if approved, Hashems Harvest may furnish this authorization to secure the information they need to establish a business relationship.

 

______________________________                           _________________________

                              Name                                                                      Title

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