SUPPLIER INFORMATION FORM
Date
Company Name
Street Address
P O Box
City
P O Box City
State / Postal Code
PO State / Postal Code
Company Website
REMIT-TO INFORMATION:
Payment/ Pay Advice (ACH) sent to this address. Provide contact information for payment-related issues
Mailing Address
City
State
Contact Name
Postal Code
Email
Telephone
Fax
CONTRACT ADMINISTRATION INFORMATION:
For contract-related issues (Terms &Conditions, Contract Pricing, etc.)
Contract Admin Name
Email
Telephone
Cell Phone
SALES/SERVICE INFORMATION:
Fax
To order materials / services
Contact Name
Email
Telephone
Cell Phone
Fax
BUSINESS CLASSIFICATION & REQUIRED TAX DOCUMENTATION
The following business entities must provide Form W-9. If located outside of California, must also provide Form CA590 or CA587.
U.S. Individual/Sole Proprietor
First Name:
Last Name:
U.S. Partnership
U.S. Limited Liability Company
U.S. Corporation
Providing Health Care/Legal Services
Other than Health Care/Legal Services
U.S. Federal, State, Local Government or Agency
Exempt Payee (provide Form W-9 or 501C3)
Non-U.S. Entity (Must provide Aera Energy LLC Non -US Certification Document or IRS W-8BEN or IRS W-8ECI AND CA 590 or CA 587
Is your company a minority-owned or women-owned business enterprise (MBE/WBE)?
If yes check appropriate boxes:
Female
Male
Asian Indian American
Asian Pacific American
Black American
Caucasian
Yes
No
Hispanic American
Native American
Is your company a DOBE or QIC?
DOBE (Duly Organized Business Entity): A corporation, limited liability company, partnership, limited liability
partnership or sole proprietor with two or more employees.
QIC (Qualified Individual Contractor): A person, including a sole proprietor with less than two full-time employees.
If your company is a QIC, please answer the questions below:
Yes
No If yes, attach
Does your company have a current business or contractor’s license?
copy of license.
Does your company have an established place of business outside of Aera?
Will ALL required duties of your company be performed off of Aera property?
Does your company provide their own company or personal vehicles, tools, equipment, computers, etc?
Does your company determine their own work schedules and set their own hours?
QIC companies: Attach copy of current Business or Contractor’s License
Supplier Information Form
Yes
Yes
Yes
Yes
No
No
No
No
Revised 7/6/2011