Vendor Application

 


Please fill out and print the form below, and either fax to: 701-775-8479, or mail it to:
ICS, Inc.
3102 North Washington
Grand Forks, ND 58203

Application Type  New Vendor  Reactivate Vendor  Address Change
Vendor Number
(Existing Vendors)
Vendor Type  Corporation  Government Agency  Individual/Sole Propietor
 Non-Profit  Partnership
Name
 (As it appears on checks; No Abbreviations.)
Doing Business As
 (If different than name on check.)
Business Classification  Small Business  Disadvantaged
 Woman Owned  Veteran Owned
(Check all that apply) *Please attach supporting documentation
Business Address
City State Zip
 Accounts Receivable Contact
Phone Number
Fax Number
E-Mail Address
Send Payments To (If different from Business Address)
City State Zip
Phone Number
Fax Number
Owner of the Tax Payer Identification Number (TIN or SSN)
Name
Social Security Number
Federal TIN
If you would like to enroll in EFT please complete the following fields
 Financial Institution
Routing Number
Account Number
Enter Your Name
Enter the Date
Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number or I am waiting for a number to be issued.

Please fill out completely. An incomplete form will create a delay in our payment(s) to you and your payment(s) could be subject to the IRS required back-up withholding.