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2. Contact the Finance Department

   P.O. Drawer 400
   2671 San Angelo
   Ingleside, TX 78362

   Phone: 361-776-2517
   Email the Finance Department

4. Vendor

   1. New Vendor
   2. Update Vendor
6. Name or Business Name*

   As shown on income tax return & field 1 of W9

8. Remittance Address

   If different from fields 5&6 on W9

10. City*
11. State*
12. Zip Code*
14. Email Address*
15. Business Phone Number*
17. Billing Contact Person*
19. You must furnish a copy of the following items to the Finance Department for your registration to be completed

    1. Form W-9

21. Checks will be made out to the name listed in field 1 of the W-9. DBA listed in field 2 of W-9 will be shown below. Checks will be mailed to the address listed in field 5 & 6 on W-9, unless a separate remittance address is listed on this form. Form-1099 will be mailed to the address listed in the W-9 without exception.

23. Name
25. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
27. Electronic Signature*
28. Date*
    Date
32. Office Use Only
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field