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Vendor Registration
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Vendor Application Form
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This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Vendor Information
This section is complete
This section is incomplete
2.
Automatic Payment Authorization Agreement (Optional)
This section is complete
This section is incomplete
3.
Independent Contractor vs. Employee Checklist
This section is complete
This section is incomplete
Vendor Information
Instructions
Vendors please complete the entire application.
Vendor Name
Does business have less than three employees?
If you indicated yes, please complete the independent contractor vs. employee checklist.
Yes
No
Payment Street Address
Payment City
Contact Name
P.O. Box
State
Zip Code
Email Address
Order Street Address
Order City
Contact Name
P.O. Box
State
Zip Code
Email Address
Phone Number 1
Phone Number 2
Fax Number 1
Fax Number 2
Terms
Discount
Are you a certified minority business enterprise?
Yes
No
If you indicated yes, please check one of the following that best describes your business:
African American
American Indian
Asian American
Disabled as defined in GS 168-1 or GS 168A-3
Female
Hispanic
Non-profit work center for blind; severely disabled as defined in GS143-48
Socially and economically disadvantaged as defined in 15 USC 637
Signature
Date
Title
Continue
Automatic Payment Authorization Agreement (Optional)
Vendor Name
Phone Number
Please select one of the following
First time request for automatic payment
Request to change automatic payment information
Bank Account Information
I hereby authorize the City of Jacksonville to initiate deposits to the checking account described below.
I authorize
Checking Accounts Only
Banking Institution (Name)
Street Address
P.O. Box
City
State
Zip Code
Bank Routing Number
Checking Account Number
Title
Phone Number
Deposit Notification Information
I hereby authorize the following individual to receive notification via email of payment details of all funds deposited to the above account:
Print or Type Name
Email (for notification)
Term
This authority will remain in full force and effect until the City of Jacksonville has received written notification of discontinuation and in such manner as to afford the City of Jacksonville and depository a reasonable opportunity to act on it.
Officer Name (Print or Type Name)
Signature
Title
Phone Number
Date
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Independent Contractor vs. Employee Checklist
Instructions
Vendors complete this page if you answered yes to having less than three employees.
Whenever the City of Jacksonville retains an independent contractor who does not carry workers’ compensation insurance and the owner or an employee of that contractor is injured, a determination must be made as to whether the injured worker is truly an independent contractor or, in fact, is an employee of the City of Jacksonville. The North Carolina Industrial Commission and North Carolina Courts have used the following tests to make this determination. Please complete the information below for your company.
Name of Company / Business / Individual
Total Number of Employees (excluding owner)
Type of Work Performed
Are you engaged in an independent business or occupation?
Yes
No
Do you or your company / business have a federal tax ID number?
Yes
No
Do you or your company / business perform similar work for others?
Yes
No
Do you or a representative of your company / business have the freedom to use assistants / helpers as he/she may think proper?
Yes
No
Do you or the assigned representative have full control over such assistants / helpers?
Yes
No
Do you or your company / business determine the time to perform work? For example, the City of Jacksonville does not tell you to work specific hours during the day.
Yes
No
Do you or your company / business have the independent use of his/her special skill, knowledge, or training in the execution of the work?
Yes
No
Are you or your company / business doing a specified piece of work at a fixed price or for a lump sum (not paid by the hour)?
Yes
No
Do you or your company / business have the freedom to use their method of doing the work rather than another and are not subject to discharge because one method is adopted over another method?
Yes
No
Does the City of Jacksonville furnish tools or equipment for you or your company / business to use in completing the work?
Yes
No
None of these factors are controlling, but each is to be considered in determining the relationship between the parties. The essential issue is whether the alleged employer has the right to control the method and means by which the “employee” performs their work.
Contractor Signature
Date
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Receive an email copy of this form.
Email address
This field is not part of the form submission.
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