Supplier Registration Form
Substitute IRS Form W-9

If you are interested in forming a business partnership with Xavier, please fill out our secure form below. Federal law requires Xavier University to provide Taxpayer Reporting information (1099.1042S forms) to the Federal Government and the payee on certain types of payments.

Supplier Information

Ordering Address

Payment Address

Organization Information

Organization Type *

If Sole Proprietor, Partnership, Incorporated Business, Limited Liability Company, Non-Profit Organization, or Government Entity. If Individual, please enter "000" (three zeros).

Tax Classification

If Limited Liability Company.

Business Classification

Minority-Owned Business

% Ownership

% Ownership

% Ownership

% Ownership

% Ownership

% Ownership

 

Woman-Owned Business

Veteran Owned?

Service Disabled Veteran?

Terms

Conflict of Interest

A conflict of interest may exist in a situation where a Xavier employee and/or his or her spouse or emancipated minor children has a connection to the above referenced supplier, and a reasonable person would think this relationship would compromise the competitive process.

Does any individual employed by Xavier have a significant interest in your business? *

Preparer's Information

UNDER PENALTY OF PERJURY, I CERTIFY THAT:
THE NUMBER SHOWN ON THIS FORM IS MY CORRECT TAXPAYER IDENTIFICATION NUMBER AND ALL OTHER RESPONSES PROVIDED THEREIN, INCLUDING VENDOR CLASSIFICATIONS, ARE TRUE AND ACCURATE. I AM NOT SUBJECT TO BACKUP WITHHOLDING DUE TO FAILURE TO REPORT INTEREST AND DIVIDEND INCOME. THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISIONS OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.

Penalties and Remedies:


Anyone who misrepresents any aspect of the status of a concern for the purposes of securing an order may:

(A) Be punished by imposition of a fine, imprisonment, or both;
(B) Be subject to administrative remedies, including suspension and debarment; and
(C) Be ineligible for participation in programs conducted under the authority of the Small Business Act.