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2. 
3. 
   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
4. VENDOR ENROLLMENT FORM
6. VENDOR INFORMATION
7. Date*
   Date
9. Company Name*
   (Must Match W9)
10. Company DBA
12. Company Owner (if applicable)
    
    First Name
13. 
    
    Last Name
15. Vendor Website
17. Vendor Type

    (check all that apply)

    1. Disabled Veteran
    2. HUB

    1. Minority-Owned
    2. Local Business (in Humboldt)

    1. Section-8
    2. Small Business

    1. Woman-Owned
19. California Vendors:

    1. Business
    2. Professional
20. State License #
21. City License #
22. County License #
26. SALES CONTACT INFORMATION
28. First Name*
29. Last Name*
31. Order Address
    
    Address Line 1*
32. 
    
    Address Line 2
34. City*
35. State*
36. Zip*
38. Order Phone Number (toll-free preferred)*
39. Order Fax
41. *ORDER* Email Address (general mailbox preferred)
43. Do you accept purchase orders?

    1. Yes

    1. No
44. Via Email?

    1. Yes

    1. No
46. Does the County of Humboldt currently have an account with your company?

    If Yes, please list all account numbers

    1. Yes
    2. No
47. Account Numbers
51. BILLING CONTACT INFORMATION
53. First Name*
54. Last Name*
56. Payment Remit-To Address
    
    Address Line 1*
57. 
    
    Address Line 2
59. City*
60. State*
61. Zip*
63. Accounts Receivable Phone Number*
64. Accounts Receivable Fax
66. Accounts Receivable Email Address
67. Can you email invoices?

    1. Yes

    1. No

    Yes is preferred
69. County Bill-To Address
    Submit invoices to contact address on purchase order(s) or in accordance with contract terms.
73. RESPONDENT
75. You are required to submit a W-9 with this form. (unless previously submitted)
    Is your W-9 attached?

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

    1. Yes

    1. No
76. Attach W-9 here
78. Sole Proprietor?*

    1. Yes

    1. No

    ***If "Yes" is checked - a Social Security Number is required on your W-9 by the state of CA***
80. Person Completing Form
    
    First Name*
81. 
    
    Last Name*
82. 
    
    Business Title*
84. Phone Number*
85. Email Address
89. PAYMENT INFORMATION
91. What are your payment terms?*
92. Negotiable discount based on business volume?

    1. Yes

    1. No
94. Accept payment by check or EFT?

    1. Yes

    1. No
95. Preferred Method of Payment*
    -- Select One --CheckEFT

    If EFT, see instructions below
97. EFT Payments
    
    Email for remittance advice (Required for EFT payments*)
    
    ***One of the following uploads is required to sign up for EFT payments***
99. Option A:
    
    A voided check
    (upload here)
100. 
     
                OR
101. Option B:
     
     A letter from your bank
     (upload here)
     Must include:
     *Verification of account ownership
     *Bank routing number
     *Bank account number
105. For inquiries, please contact us at (707) 268-2544 at Purchasing@co.humboldt.ca.us.
107. Vendors who wish to be notified of County Bids and RFPs must register online at:
     http://humboldtgov.org/list.aspx
108. County purchase order terms and conditions may be reviewed at:
     http://humboldtgov.org/2163/POTC
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field