Vendor Intake Form

Payment Information

For payment of US Dollars to Subcontractor/Vendor accounts within the United States
Is Payment/Remit Name and Address same as Legal Name/Corporate Address?

YesNo
Payment/Remit Name
(if different from Company Name, dba etc)
Payment/Remit Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FEIN/SSN
Payment Contact Name
Payment Contact Email
example@example.com
Payment Contact Number
Please enter a valid phone number.
Controller's Name
If different from Payment Contact
Controller's Email
If different from Payment Contact
Controller's Phone Number
If different from Payment Contact
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Name
Routing Number
Bank Account Number
Account Type
Bank Contact Name
Bank Phone Number
Please enter a valid phone number.
Attach W-9 signed within the last 12 months

Cancelof
Is 1099 required for your company?

YesNo

Certification and Signature
I am authorized to make legally binding commitments on behalf of Subcontractor/Vendor hereby certify that the classifications claimed herein are true and correct and shall provide evidence of registration and/or certification to Integral. I understand that false representations are punishable under 15 U.S. Code, Section 645(d). Subcontractor shall be responsible for keeping all registrations and certifications required by law, current and in effect. *
I acknowledge that all invoices and statements must be sent to ap@integral-corp.com to ensure timely processing*
Signature*

Clear
Signer Name*
Signer Title*
Signer Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date

MonthDayYear
Date
Should be Empty:

Payment Information