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UVA Health Substitute Form W-9 and Vendor Registration Form
ATTENTION - Tax, legal or Accounts Receivable (QUICK RESPONSE WILL PREVENT PAYMENT DELAY)
Vendor Registration Frequently Asked Questions (FAQ) and Information Sheet
Please complete the following form to register as a vendor with UVA Health.
All fields marked with an asterisk (*) are required.
Company's Legal Name *
Additional Name(s) DBA's
(If Applicable)
Business Email Address *
Business Phone Number *
Select TAX ID Type
(Federal Employer ID Number or Social Security Number)
FEIN
SSN
TAX ID *
1099 Requirement *
1099N
1099M
Both: 1099N and 1099M
Neither
DUN & Bradstreet #
(If Applicable)
Legal Address Street *
Legal Address City *
Legal Address State *
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
N/A - Foreign Vendor
Legal Address Postal Code *
Ordering Address Street *
Ordering Address City *
Ordering Address State *
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
N/A - Foreign Vendor
Ordering Address Postal Code *
Ordering Email Address
Remittance Address Street *
Remittance Address City *
Remittance Address State *
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
N/A - Foreign Vendor
Remittance Address Postal Code *
Remittance Email Address
* If your company is considered a foreign vendor, please list N/A for your state as this is a required field *
Supplier Type *
Classes which may be reportable to the U.S. Internal Revenue Service
Please select one of the following:
Individual
Sole Proprietor
Partnership
Sub-Chapter S Corporation
Corporation
Corporation Providing Professional Physician, Nursing Services, etc. to patients
Corporation Providing Legal Services
Limited Liability Company
Federal or Virginia State Government
Local Virginia or Other State Government
Non-Profit Organization
Foreign Company
Is your company a SWAM Vendor? *
Select an option
Yes
No
Small Business, Women-Owned Business and Minority Business Status information (SWAM), please select one or more of the following:
Small Business Enterprise (together with affiliates, having fewer than 250 employees or $10 million annual receipts or less, averaged over the previous 3 years.)
Minority-Owned Business (51 % owned by one or more minorities, and whose management and daily business operations are controlled by such individuals.)
Woman-Owned Business Enterprise (51% owned by one or more women, and whose management and daily operations are controlled by such individuals.)
Disadvantaged Business Enterprise (51% owned by one or more socially and economically disadvantaged individuals, and whose management and daily operations are controlled by such individuals.)
Micro-business: a certified small business that has no more than twenty-five (25) employees and no more than $3 million in average annual revenue over the three-year period prior to certification.
Minority Business Enterprise Certification:
To be included in benefits of State procurement opportunities, entities must be certified by the Commonwealth of Virginia. However, no vendor shall be to certify under this program and no vendor shall be excluded from doing business with the Commonwealth because of their failure to become certified. For information regarding certification, contact the Virginia Department of Minority Business Enterprise, 200 N 9th St., Richmond, VA 23219 or call (804) 786-5560 from 8:00am to 5:00pm or access their website at
www.dmbe.state.va.us
.
Are you already certified with the Virginia Department of Minority Business Enterprise?
Select an option
Yes
No
If yes, assigned ID #
Was this a UVA Health employee request?*
Select an option
Yes
No
If you answered yes to the above please provide the email address of the UVA Health requestor who sent you the request to complete the form.
Guidelines for Accepting Orders from UVA Health:
Always provide a purchase order number (PO) on all billing documents/invoices.
Rector & Visitors of the University of Virginia doing business as UVA Health.
Email:
ghxodap.universityofVirginia@na.firstsource.com
Mail To:
Post Office Box 31260
Salt Lake City, UT 84131
United States
Be aware that the Medical Center processes its purchase orders independent of the University of Virginia.
All invoices are required to have a purchase order in order to be processed.
Certification (required)
The number(s) shown on this form are the correct taxpayer number(s) and the names indicated are the legal names on file with the IRS or SSA.
I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding or the IRS has notified me that I am no longer subject to backup withholding.
(Check here if you have been notified by the IRS that you are currently subject to backup withholding.)
Neither I nor any immediate family member is currently an employee of the University of Virginia, University of Virginia Medical Center or any other state agency of the Commonwealth of Virginia. "Immediate family" means (i) a spouse and (ii) any other person residing in the same household with you, who is your dependent or of whom you are a dependent. A "dependent" means a son, daughter, father, mother, brother, sister or other person, whether or not related by blood or marriage, if such person receives from you, or provides to you, more than one-half of his or your financial support. If you or an immediate family member are an employee, please call our Director of Contracts and Procurement at
JDH8R@uvahealth.org
or (434) 924-2542 for guidance.
Please attach your W-8, W-9 or other supporting documents*
Please select at least one file.
If this form was requested due to changes in your company (e.g., merger, acquisition, name change), please attach documentation detailing these changes. For future updates related to company name, addresses, tax information, mergers, or acquisitions, contact us at
RUVAMCVR@uvahealth.org
. For banking or payment inquiries, reach out to our Accounts Payable department at
rhealthap@uvahealth.org
. For questions regarding purchasing or to contact a buyer, please contact our Procurement Team at
AskProcurementOPS@uvahealth.org
.
Authorized Signature (type your first, middle, last name)*
Authorized Title *
Authorized Date *
Submit
Reset
Medical Center Supply Chain Data Integrity
Contact us:
RUVAMCR@uvahealth.org