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2. City Vendor Number if previously assigned:
4. Name (List legal name, if joint names, list first the name of the person whose TIN you enter in Part I - See Specific Instructions on page 2.)
6. Business Name, if different from above. (See Specific Instructions on page 2.)
8. Check appropriate box:

   1. Individual
   2. Sole Proprietor
   3. Corporation
   4. Partnership
   5. Other
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
17. Fax Number
19. Email Address
21. Remittance Address
23. City
24. State
25. Zip Code
27. Phone Number
28. Fax Number
30. Email Address
32. Taxpayer Identification Number (TIN)
    Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. For other entities, it is your employer identification number (EIN).
34. EIN-TIN Number
36. Supplemental Vendor Information(Check ALL that apply):

    1. Rent
    2. Small Business
    3. Day Care Provider
    4. City of Roanoke Employee
    5. Minority Owned Business
    6. Foster Care / Adoptive Parent
    7. Roanoke City Public Schools employee
    8. Women Owned Business
    9. Other Social Services Provider
38. Upload your W9
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field