CMHPSM New Vendor Form

Vendor Name: *

DBA or Business Name if Different: *

Vendor Type: *

Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Limited Liability Company Other

Other:

Federal ID

or

Social Security #

Vendor Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Main Phone: *

Area Code Phone Number

Main Fax: *

Area Code Phone Number

All CMHPSM vendors must submit a signed W-9 form and upload it below.

Link to fillable PDF copy of W-9 form: Federal W-9 Form

W-9 Upload

Contact Name: *

First Name Last Name

Contact Phone: *

Area Code Phone Number

Contact E-mail: *

All CMHPSM vendors will be paid through an electronic direct payment via ACH, instead of paper checks, unless the CMHPSM approves a paper check for an emergency or as an exception.

Financial Institution Name: *

Routing #: *

Account #: *

Type: *

Checking Savings

Remit E-mail: *

I understand this authorization remains in effect until cancelled by the Vendor or the CMHPSM. I authorize the CMHPSM to recover money electronically deposited in error by either debiting my account or by adjusting future payments. I understand I will be notified if an error does occur. Michigan law governs electronic funds transactions authorized by this agreement in all respects except as otherwise superseded by federal law.

Vendor agrees to these stipulations by checking the agree box or signing or typing in the signature box:

Authorizer: *

First Name Last Name

Date: *

Month Day Year

Agree: *

Agree to Conditions