Vendor Master Data Template - Shared Services Home Page

Vendor Master Data Template
Completion of this form is required to establish your company as an authorized vendor in Johns Hopkins' Vendor System.
Please print clearly or type.
Vendor Number:
Vendor Master Phone Number:
Vendor Master Fax Number:
Verification Date:
Requestor Name:
Requestor Phone Number:
Does your company have the ability for electronic ordering and billing? Yes No Requestor Fax Number:
SALES OFFICE ADDRESS (for mailing/correspondence related to Purchase Orders)
Requestor Email:
Internal Use Only
443-997-1000
443-997-5699
Full Legal Name of
Business As
Reportable to IRS
DBA:
Are hard copies of telephone confirming orders required?
Street Address:
Yes No
REQUEST FOR TAXPAYER ID NUMBER & CERTIFICATION (Substitute W-9)- Please indicate
Social Security Number (SSN) or Federal Tax ID Number (TIN) for your type of organization below:
Individual/Sole-proprietorship (provide S.S.N.)
Vendor is a Partnership (provide TIN)
Corporation (provide TIN)
Other Types (i.e: LLC, LLP)
City:
County:
REMITTANCE ADDRESS
Name to Print on Checks:
Street Address
As Will Appear on Invoice:
City:
County:
State/Country:
Zip Code:
Sales Person's Name:
State/Country:
Zip Code:
A/R Contact Name:
Phone Number:
Alternate Phone Number:
Fax Number:
Phone Number:
Alternate Phone Number:
Fax Number:
SOCIO-ECONOMIC STATUS - Check All That Apply (based on primary NAICS/MCC Code)
Primary NAICS Code
Small Business Historically Black College HUBZone Certified (attach certification)
Ownership Ethnicity
SBA Certified SDB Foreign Owned Business (must have W8 attached) Veteran (Asian-Pacific Americans, Native Americans,
Large Business Women Owned Business (cannot be checked alone) Service Disabled Veteran African-Americans, Hispanic Americans,
US Government Agency Non-Profit Organization Other Subcontinent-Asian Americans)
TERMS OF PAYMENT FOB E-MAIL CONTACT
Do you accept MasterCard/Visa Cards? Yes No Year Company Established: Sales Volume: Year:
CERTIFICATION: Under penalties of perjury, I certify that: 1) the number shown on this form is my correct T.I.N., 2) I am not subject to backup withholding because a) I am exempt from backup withholding or b) I
have not been notified by the IRS that I am 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 no longer subject to backup withholding, and 3) I
am a US person (including a US resident alien).
Printed Name of Authorized Vendor Representative
Signature of US Person & Certification of Substitute W-9 Information
Revision date: 04/19/2013
X
Return completed form to the Vendor Master Data Representative to the fax number 443-997-5699 or mail to Johns Hopkins University, 3910 Keswick Road, Suite N4300, Baltimore, MD 21211.
Date

Vendor Information
Please specify if your company is capable to handle ecommerce ordering and billing.
Vendor/Payee Name Please provide the name of your firm for payment purposes.
If you require a hard copy purchase order prior to shipment, please check the appropriate box.
Purchasing Location - Please provide the address and appropriate information for the
Purchasing Location for your firm. This should be the location to which Purchase orders should
be sent.
Be advised that all Johns Hopkins purchase orders are subject to certain Terms and Conditions,
located on Johns Hopkins' Procurement Web site.
http://ssc.jhmi.edu/supplychain/terms-jhu.html http://ssc.jhmi.edu/supplychain/terms-jhhs.html
Remit Location - Please provide the address and appropriate information for the remittance
location of your firm.
Tax Information Substitute W-9
Federal Tax Identification Number
Please enter your Taxpayer Identification Number (TIN). For individuals or sole proprietors, this
is your Social Security Number (SSN). For a foreign individual who is not a U.S. citizen or
permanent resident, this is either your Social Security Number (SSN) or your Individual Taxpayer
Identification Number (ITIN). For a business, this is your federal (not State) Entity Identification
Number (EIN).
If you are an individual, you must generally enter the name shown on your Social Security
Card. If you have changed your last name, for instance, due to marriage, without informing
the social security administration of the name change, enter your first name, the last name
shown on your Social Security Card and your new last name. If the account is in joint
names, list first the person or entity whose TIN number you used above.
Sole Proprietors must use their individual name as shown on their Social Security Card.
This is especially important if operating your business as with a Business, Trade Name,
"Doing Business As (DBA)" name.
Business Classification
Please check all classifications that apply.
Small Business is a domestic concern that normally employs, with its affiliates, not more than
500 persons, or as defined by Section 3 of the Small Business Act. A Small Business Concern is
one which: a) is independently owned and operated. b) is not dominant in the field of its
operation c) qualified under the criteria covering annual receipts set forth in Section 3 of the
Small Business Act and d) does not employ more than 500 employees.
Minority Owned Business (SDB) is a small business in which 51 % of the business or stock is
owned, and management of daily business operations is controlled by, one or more members of
the following groups classified by the government as socially or economically disadvantaged
individuals, or any other minority group or individual found to be disadvantaged pursuant to
Section 8 (a) of the Small Business Act.
Black Americans, Hispanic Americans Native Americans include American Indians,
Eskimos, Aleuts and Native Hawaiians. Asian Pacific Americans include U.S. Citizens
whose origins are in Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam,
the U.S. Trust Territory of the Pacific Islands, the Northern Mariana Islands, or the
Federated States of Micronesia. Subcontinent-Asian Americans include U.S. citizens
whose origins are in India, Pakistan, Sri Lanka, Bhutan, or Nepal.
Large Business is a domestic concern that does not meet the criteria for qualifying as a small
business.
Historically Black College or University is an institution determined by the Secretary of Education
to meet the requirements of 34 CFR 608.2. For the Department of Defense (DoD), the National
Aeronautics and Space Administration (NASA), and the Coast Guard, the term also includes any
nonprofit research institution that was an integral part of such a college or university before
November 14, 1986.
Woman Owned Business is a small business concern owned, controlled and operated by
women, where: a) at least 51 percent of the stock of which is owned by one or more women; or
in the case of any publicly owned business, at least 51% of the stock of which is owned by one
or more women; and b) the management and daily business operations or the business is
controlled by one or more women.
HUBZone Small Business is a small business concern that appears on the List of Qualified
HUBZone Small Business Concerns maintained by the Small Business Administration.
Veteran-Owned Small Business is a small business concern not less than 51 percent of which is
owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly
owned business, not less than 51 percent of the stock of which is owned by one or more
veterans; and the management and daily business operations of which are controlled by one or
more veterans.
Service-Disabled Veteran-Owned Small Business is a small business concern not less than 51
percent of which is owned by one or more service-disabled veterans (as defined at 38 U.S.C.
101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16)) or, in the
case of any publicly owned business, not less than 51 percent of the stock of which is owned by
one or more service-disabled veterans; and the management and daily business operations of
which are controlled by one or more service-disabled veterans or, in the case of a servicedisabled
veteran with permanent and severe disability, the spouse or permanent caregiver of
such veteran.
Terms of Payment Fill in your company’s payment terms
FOB Fill in your company’s delivery information
Email Contact Enter the email address of the person who can answer questions regarding the
information submitted on this form.
Purchasing Cards If you accept MasterCard/Visa purchasing cards, please check the
appropriate box.
Year Company Establish Enter the year that the company was establish.
Sales Volume Enter your most recent annual sales volume and the corresponding year.
Certification The authorized representative should print his/her name, and sign and date the
form.
Foreign National Information
Special Note for Visitors on J-Visas: Visitors on J visas not sponsored by Johns Hopkins
University Must obtain written permission from the International Office of the sponsoring
institution prior to receiving honoraria or service payments from Johns Hopkins.
Special Note for Visitors on TN, H-1B or O Visas:
Visitors on TN, H-I B or O visas not sponsored by Johns Hopkins University may NOT receive
honoraria or service payments from Johns Hopkins.
Questions?
If you have any questions pertaining to this form, please call Johns Hopkins Supply Chain
Shared Services @ (443) 997-1000.