Data Collection Form - PHA Vendor/Eprocurement/ACH Initiative

Contracts/Procurement Office

3100 Penrose Ferry Road

Philadelphia, PA19145

Fax: 215 684-4092

Email:

PHA Vendor Add or Update Form

(Please check above as applicable)

(*) Denotes a required field

Vendor number assigned by PHA:

1. Main Location Section

*Vendor Name:

(Please use the Legal Name as it appears on the W9 form)

/ Year Company Established:
*Company Type /

CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP

If other, please specify type:

*Legal Address Line 1
Legal Address Line 2
*City /

*State

*Zip Code

*Phone 1 /

Phone 2

*Email
*Fax Number /

Website

NAICS Code (s): List North American Industry Classification System (NAICS) Codes for products and/or services that your business entity offers. Please visit to see current NAICS codes.

Record up to six SIC Codes for this location in the spaces below. At least one SIC Code must be entered.

*NAICS 1

NAICS 2

NAICS 3

NAICS 4

NAICS 5

NAICS 6

*Tax Identification Number (TIN)
(Must be 9 digits) /

If Sole Proprietor (Withholding, 1099) enter your SSN in lieu of the TIN: -- --

Do you have a Parent Company? /

YES OR NO

If YES, please provide us with information about your Parent Company information in Section 3 below.

2. Remit to/Payment Section (Location #1)

If same as Main Location check here:

Company Name
Company Type /

CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP

If other, please specify type:

Legal Address Line 1
Legal Address Line 2
City /

State

Zip Code

Phone 1 /

Phone 2

Email
Fax Number /

Website

3. Parent Company Section (Location #2)

If same as Main Location, check here:

Company Name
Company Type /

CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP

If other, please specify type:

Legal Address Line 1
Legal Address Line 2
City /

State

Zip Code

Phone 1 /

Phone 2

Fax Number /

Website

Email
Tax Identification Number (TIN)
(Must be 9 digits) /

If Sole Proprietor (Withholding, 1099) enter your SSN in lieu of the TIN: -- --

4. Return To Vendor/Material Return Section (Location #3)

If same as Main Location, check here:

Company Name
Company Type /

CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP

If other, please specify type:

Legal Address Line 1
Legal Address Line 2
City /

State

Zip Code

Phone 1 /

Phone 2

Fax Number /

Website

Email
Tax Identification Number (TIN)
(Must be 9 digits) /

If Sole Proprietor (Withholding, 1099) enter your SSN in lieu of the TIN: -- --

5. Contact Information

Please supply contact information for the people in your company that currently fill the following roles:

CEO - to provide a contact that can commit your company
CFO - to provide a contact that can provide financial and banking information
Sales Representative / Accounting Manager – to identify a regular business contact

* Denotes a required field

**Location: In this field, please indicate the location number from above where this contact conducts business. E.g. If your CEO operates from your Parent Company, the Location number would be 2.

Role / Location# from above** / Name /

Title

/ Phone Number / Fax
Number / Email
CEO

CFO

SALES REP or ACCT MGR
OTHER

6. ACH information: (*) Denotes a required field

Please supply all banking information below.

*Name of Bank: / *Identify Branch Name and Location:
Bank’s ACH Coordinator / Bank’s ACH Coordinator Phone number:
*Vendor Name (as it appears on account): / *Branch Name / Branch ID #:
*Bank Account #: / *Account Type:
*Transit Routing # (Enter 9 digits, one digit in each space provided):
- / - / - / - / - / - / - / -
/ Click here if your company does not have the ability to complete ACH transactions:

7. Company Profile:

If you answer YES to questions 7.a or 7.c, you must supply the certification information below and provide supporting documentation.

7.a. Is the company Minority Owned? NOYES

If yes,

Name of Certification Agency:

Certification No:

Term Start Date:

Term End Date:

7.b. If the company is Minority Owned, please indicate the company’s Racial/Ethnicity Classification (you can only check one):

White American
Black American
Native American
Hispanic American
Asian/Pacific American
Hasidic Jew

7.c. Is the company Woman Owned? NOYES

If yes,

Name of Certification Agency:

Certification No:

Term Start Date:

Term End Date:

7.d. Does your company qualify as a Section 3 Vendor under HUD’s Section 3 Act of 1968?

YES OR NO

Please visit for details on HUD’s Section 3 program.

7.e. Can PHA email PO’s to your company instead of fax or mail?NOYES / If Yes, email address for Purchase Orders:

8. By clicking here, I certify that I am authorized to supply this information and that the all the information provided is true the best of my knowledge. Name:

Data Collection Form - PHA Vendor/Eprocurement/ACH Initiative

PHA Vendor Add or Update Form

1. Main Location Section

(Please use the Legal Name as it appears on the W9 form)

CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP

If other, please specify type:

*State

*Zip Code

Phone 2

Website

NAICS Code (s): List North American Industry Classification System (NAICS) Codes for products and/or services that your business entity offers. Please visit to see current NAICS codes.

Record up to six SIC Codes for this location in the spaces below. At least one SIC Code must be entered.

*NAICS 1

Title

7.b. If the company is Minority Owned, please indicate the company’s Racial/Ethnicity Classification (you can only check one):

Please include the following enclosures when returning this form to PHA:

Below section MUST be Completed by PHA PROCESSOR.

Vendor Add/Update Completed:

By: ______

Printed Name of PHA Processor

______

Signature of PHA Processor

add/Update Entered in PS System:

Date: ______

Vendor Number: ______

Vendor ShortName: ______