Vendor Qualification Form

Vendor Qualification Form
Eagle Mountain Staff Contact:
Please list name of contact you're working with at the city.
EMC Staff Contact Email
example@emcity.org
Legal Company Name:
Years in Business
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Organization Type:
Entity / State Business License Number
State of Utah issued number.
Principal Product/Service:
Number of Employees
Do you or anyone in your company have a personal or family relationship with any Eagle Mountain City employee?
Please Describe:
Are any of your products/services on the Utah State Cooperative Purchase Contract?
Please list the contract numbers:
We are a participating employer with the Utah Retirement Systems (URS). Are you receiving a retirement pension from URS?

Payment Information
Accounts Receivable Contact

First NameLast Name
Accounts Receivable Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Accounts Receivable Email
example@example.com
Do you require a purchase order for all purchases?
Would you like to receive payments through ACH Direct Deposit? (Only within the United States)
Name of Financial Institution
Branch Number (Optional)
Bank Routing Number
Account Number
Account Type

Business References

Please list two customers (preferably government entities)
Reference 1 Name:
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Name:
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Please attach your W-9 or W-8 (Foreign Entities)

PDF formatting only
Cancelof
Will work or services be performed on Eagle Mountain City property?
Please upload a certificate of liability insurance

Please ensure Description of Operations and Certificate Holder fields have Eagle Mountain City identified.
Cancelof

Eagle Mountain Purchasing Guidelines
- Eagle Mountain City requires a purchase order.
- Payment terms are always net 30.
- Please e-mail invoices to ap@eaglemountain.gov
- No payments for service will be made without a W9 or W8 on file.
I have read and agree to adhere to Eagle Mountain City's purchasing guidelines

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Printed Name
Title
ACH Direct Deposit Authorization

The company named above (“Company”) herby authorizes and request Eagle Mountain City to make electronic payments to the financial institution named in this form. Company Authorizes Eagle Mountain City to retract or correct any amounts deposited into Company’s account in error. Eagle Mountain City will notify the Company prior to any retraction or corrections of deposited amounts. The company will reimburse Eagle Mountain City in full upon demand any incorrect deposits into the Company’s account which are not recovered by Eagle Mountain City. In the event the Company changes its banking instructions or closes the account, the Company agrees to notify Eagle Mountain City immediately. The company understands that the actual deposits of the funds to the Company’s account will be the responsibility of the financial institution. ACH Direct Deposits will only be made within the United States.
PRIVACY NOTICE

Eagle Mountain City is committed to protecting your privacy. The personal data you provide on this form is collected for the purpose of setting up vendor accounts, processing payment information, tax documents and verifying identity and will be used only for those purposes. If you choose not to provide the requested information, we may be unable to process your request or provide the service you are seeking.

Your information will not be sold and is not regularly disclosed to any private or governmental entities. However, it may be shared when required by law or contract. The information collected is maintained in the Eagle Mountain City Accounting Software.
Should be Empty:

Vendor Qualification Form

Payment Information

Business References

Eagle Mountain Purchasing Guidelines