Change of Vendor Information Form

Change of Vendor Information Form

Use this form to request changes to your existing vendor profile information. If you are a new vendor or if you would like to update your business name, tax classification or tax ID number, please complete the Substitute Form W-9.

If you have questions on filling out this form, please email vendor@pima.edu or call 520-206-2079.

What is your First and Last Name?*

Person completing the form

Were you asked to submit this form by an employee?

Select

> Please provide the employee's name

> Please provide the employee's Pima College email

What is your Pima College Vendor Code?

If you do not know your vendor code, please skip.

What is the name shown on your income tax return?*

Do you have a Business/Trade/DBA name?*

Select

> What is your Business/Trade/DBA name?

What is your Federal Tax ID Number (TIN)?*

EIN=Employer Identification Number, OR SSN=Social Security Number

Are you making changes to any of the following?

Only complete the sections that you would like to update

Tax Identification and Classification

> Exempt payee code

> Arizona sales tax ID (TPT)

> Main street address

Select or enter value

What is your exempt payee code (if any)?

What is your Arizona tax ID?

What is the main street address?

Main address city:

Main address state:

Main address zip code:

Vendor Terms and Diversity

> NAICS code

> Payment terms

> Vendor diversity

Select or enter value

What is your NAICS Code?

What are your payment terms?

Select

> Please specify other payment terms.*

What is your business certified as?

Select

> Please specify other diversity group.*

Vendor Contact Information

> Primary Contact's name, email, and/or phone number

> Remit address for payments

> Purchase order email

Select or enter value

What is the primary contact's name?

What is the primary contacts email?

What is the primary contact's phone number?

What is the remit address for payments?

Remit address city:

Remit address state:

Remit address zip code:

What is the email for purchase orders?

Payment/Direct Debit (ACH) Authorization

> Update direct debit/ACH information

> Add direct debit/ACH information

> Disable direct debit/ACH information

Select

> What is the name of your banking institution?*

> What is the account type?*

Select

> What is the account number?*

> What is the ACH routing number?*

> What is the email for ACH notifications?*

ACH Certification:*

I hereby certify that the above information is current and correct. Furthermore, if I have opted for direct deposit payments, I hereby authorize Pima Community College to initiate electronic transfers of funds to the account designated.

Please print your name below if you agree.

Form Date Field

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