WVFIMS Supplier/Payee
Registration Form

Add:     Modify:
Date:

     

1. Supplier/Payee:
2. SS# or FEIN:
3. Address:
          City: 


         State:               Zip Code:                   Country:

4. Business Designation: (If "SO", # 5 is required)
                         
5. Owner of Proprietorship:

6. Telephone:

7. Address Type: ("R" for Remit or "O" for Order)

8. WVFIMS Number "Requested By":

Name:
Department:
Business Phone: 

            Ext.:


9.     _____________________________________________________
        Payee Signature/Date

10.  _____________________________________________________
       Budget Officer Signature/Date
       (Required on "ALL" Registration Forms)

For Office Use Only
Date:  ____________ Added:   ______________ Modified: ____________
WVFIMS Code:    ____________________________________________________