Supplier Setup/Change Request Form (FAX)

Vendor Name
GST Reg No.
                                          Ordering Address                               Payment Address                       
Street1         
Street2         

City

         
Province/State         
Country         
Postal Code         
Contact Info. Phone       Fax 
Currency CAD        US         Other (specify)
FOB Point Campus                   Origin
Payment Terms Net 30 2%/10 1%/10 Net 7 (food only) Other
Freight Prepaid                   Collect              Prepaid & Charge
Commodity e.g. Food, Chemical, Computer
Contact Person
Name/Title       
E-mail

To your knowledge, do any Owners, Directors or Officers have immediate family members employed by The University of Western Ontario? Refer to conflict of interest policy 3.4    Yes          No

If yes please provide details:

 
Requestor Name:
Requestor Dept:    
E-mail Address:     
Phone:           Date (YY/MM/DD):

I hereby Certify the information supplied herein is accurate and complete.

Requestor Signature                                                         Approval Signature

 

Please fax to the Purchasing Dept
Suite 6100 Support Services Building
Fax: 83772       Phone: 84585