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PURCHASING VENDOR ENROLLMENT FORM

  1. Small 100 County Seal

  2. County of Humboldt....................... County Administrative Office........ Purchasing & Disposition Team... 825 5th St Rm 112 Eureka CA 95501 Ph: 707-268-2544 Fax: 707-445-7299 purchasing@co.humboldt.ca.us.....

  3. VENDOR ENROLLMENT FORM

  4. VENDOR INFORMATION

  5. (Must Match W9)

  6. Company Owner (if applicable)

  7. Vendor Type

    (check all that apply)

  8. California Vendors:

  9. SALES CONTACT INFORMATION

  10. Orders Address

  11. Do you accept purchase orders?

  12. Via Email?

  13. Does the County of Humboldt currently have an account with your company?

    If Yes, please list all account numbers

  14. BILLING CONTACT INFORMATION

  15. Payment Remit-To Address

  16. Can you email invoices?

    Yes is preferred

  17. County Bill-To Address

    Submit invoices in accordance to contract submission/contact address on purchase order(s).

  18. RESPONDENT

  19. You are required to submit a W-9 with this form. Is your W-9 attached?

    Must be in .pdf, .png or .jpeg format.

  20. Person Completing Form

  21. PAYMENT INFORMATION

  22. Negotiable discount based on business volume?

  23. Accept payment by check or EFT?

  24. Do you accept credit card payments?

  25. Discounts if paid with credit card?

  26. If ACH, please complete items 1-3 below

  27. NOTE:

    Please include a confirmation of account information on bank letterhead or a voided check. Documentation should include the name on the account, electronic routing transit number, account number, and type of account. If submitting bank letterhead, the bank officer's name and signature is required. This information will be used to verify your account number. Starter checks are not acceptable for Electronic Funds Transfer (EFT) confirmation.

  28. Account Type

  29. These numbers are on the bottom of your check

  30. CREDIT AUTHORIZATION

    By typing my/our full name(s) in the Signature field, I/we hereby authorize the County of Humboldt to initiate entries to my/our checking/savings accounts at the financial institution listed below, and if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until County of Humboldt is notified in writing to cancel it, allowing a reasonable period of time for the County of Humboldt and the financial institution listed below to act on it.

  31. If questions, please contact us at (707) 268-2544 or at Purchasing@co.humboldt.ca.us. Vendors who wish to be notified of County Bids and RFPs must register online at humboldtgov.org/list.aspx. County purchase order terms and conditions may be reviewed at humboldtgov.org/2163/POTC.

  32. Leave This Blank:

  33. This field is not part of the form submission.