New Supplier Request Form

NEW SUPPLIER REQUEST FORM

Please fill out this electronic document and email to

*FireEye Requestor*:Click here to enter text.

*SUPPLIER INFORMATION
Business Name: Click here to enter text. / Years in Business: Click here to enter text.
DBA/Alias/Alternate Name: Click here to enter text.
Business Address: Click here to enter text.
City/State: Click here to enter text. / Zip Code: Click here to enter text.
Primary Contact: Click here to enter text. / Contact Email: Click here to enter text.
Contact Phone: Click here to enter text. / Contact Position: Click here to enter text.
*REMIT TO: (Where payment will be sent, if different from above)
Remit-To Address: Click here to enter text.
City/State: Click here to enter text. / Zip Code: Click here to enter text.
A/R Contact: / A/R Email:
Payment Terms: Choose an item. / If other, specify: Click here to enter text.
Payment Method: Choose an item. / If other, specify: Click here to enter text.
Invoice Currency: Click here to enter text.
*BUSINESS DETAILS
Organization Type: Choose an item. / If other, specify: Click here to enter text.
Business Description: Click here to enter text.
Product/Service Classification Type: Choose an item. / P/S Code:Click here to enter text.
*ADDITIONAL DETAILS FOR US COMPANIES
TAX Id- type: Choose an item. / TAX Id #: Click here to enter text.
Are you exempt from backup withholding? ☐Yes ☐No
*Are you a 1099-MISC recipient? ☐Yes ☐No
*Federal Income Tax Law requires a Form 1099 Information Return with a valid Taxpayer Identification Number to be filed for certain payments over $600.00 made in the course of conducting a trade or business. Furthermore, these payments may be subject to Backup Federal Income Tax Withholding for all payees who have not submitted a valid Federal Tax Identification Number at the time of payment.
*California Franchise Tax Board requires 7% Withholding tax form distributions of California source income provided to Domestic Non-Resident contractors
Please check off appropriate box that permits to Non-Resident Contractor CA withholding:
☐Yes, withhold CA Tax from my California source income ☐No, Do not withhold taxes (Please provide a copy of approved Waiver form
Are you a Minority or Women-owned Business?:☐Yes ☐No *If yes select below
Classification:Choose an item. / Minority Type: Choose an item.
Certified By:Click here to enter text. / Expiration Date:Click here to enter text.
*ADDITIONAL DETAILS FOR NON-US COMPANIES
TAX Id- type:Choose an item. / If other, specify:Click here to enter text. / TAX Id #:Click here to enter text.
Non-US Entity: Are you providing services to FireEye US are you operating in the US? ☐Yes ☐No
If yes, please provide IRS Form W-8BEN, W-8EXP, or W-8ECI (available at IRS.gov)
If no, please provide other form of identification, such as a business license or tax id certificate
PAYMENT/FINANCIAL INSTITUTION INFORMATION
Bank Name: Click here to enter text.
Intermediary Bank (if applicable): Click here to enter text.
Bank Address:Click here to enter text.
City/State: Click here to enter text. / Zip Code: Click here to enter text.
Bank Account Number: Click here to enter text.
IBAN Account Number (For EU):Click here to enter text.
Bank Transit(ABA/Routing/CHIPS#-For US):Click here to enter text.
Bank Account Type: ☐ Checking ☐ Savings ☐ Other
For International Use:
Bank Code Type: Choose an item. / Enter Bank Code: Click here to enter text.
CERTIFICATION AND REQUIRED SIGNATURE

1. I hereby certify under penalty of perjury that the information provided is true and correct. The number shown on this form is my correct Taxpayer Identification Number, and
2. I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that I am not subject to backup withholding as a result of a failure to report all interest or dividends, or the IRS has notified me that I am not subject to backup withholding.

Electronic Signature:(Double click to sign)

FIREEYE INTERNAL
W9 Received: ☐Yes ☐No Background check: ☐Yes ☐No MSA Signed: ☐Yes ☐No
Insurance: ☐Yes ☐No NDA: ☐Yes ☐No Security Assessment ☐Yes ☐No ☐N/A

For your knowledge: FireEye Inc. SVB Wire Requirements

UK / Australia / APAC / India / Mexico/Latin America
Account / X / X / X / X / X
IBAN / X / X
Sort code / X / X
Swift Code / X / X
BSB / X
Phone # / X / X
IFSC / X
Tax ID / X / X
CLABE / X