Contractor Payment Form
All contractors must have 1099-MISC form on file in order to be paid.
Invoice Number:
Invoice Format: Initials + 2 digit month + 2 digit day + 2 digit year. Example: BA013126
Name:
*
First Name
Last Name
Business Name:
*Disregard if being paid directly.
Tax ID Number:
*Disregard if being paid directly.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of service or purchase:
-
Month
-
Day
Year
Date
Services provided on dates:
Work order type:
*
Pharmacist staffing
Technician staffing
Construction remodel or repair
Equipment repair
Equipment purchase
Cleaning
Other
Job Details:
*Required description only needed for construction, repair, or cleaning services.
Remittance $ amount requesting:
*
1099-MISC Upload:
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Invoice Upload:
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Should be Empty: