Form Obm 5657 PDF Details

The Obm 5657 form is a key document for vendors looking to engage in business with Ohio Shared Services. It serves as a comprehensive vendor information form, requiring vendors to provide detailed data across several critical areas. This form is designed to capture changes such as new vendor information alongside updates like change of contact information, address, Tax Identification Number (TIN), name, payment terms, and purchase order dispatch method, ensuring accurate and up-to-date records are maintained. It requires the attachment of certain documents, such as the W-9 or W-8ECI forms for new vendors or those changing their TIN or name, to validate the information provided. Additionally, it collects vendor details including legal business or individual name, business entity type, federal tax ID, complete address, contact information, and strategic sourcing contact information. The form also includes sections for vendors to indicate if they are certified as a Minority Business Enterprise (MBE) or part of the Encouraging Diversity, Growth, & Equity (EDGE) program, their preferred payment terms, and the method for receiving purchase orders. With an emphasis on legibility and completeness, the form underscores Ohio's commitment to streamlined, secure, and efficient vendor management processes, while cautioning vendors about the potential security risks of transmitting sensitive information through non-secure channels such as email and fax.

QuestionAnswer
Form NameForm Obm 5657
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesVendor_Informat ion_Form(OBM 5657) obm 5657 instructions form

Form Preview Example

VENDOR INFORMATION FORM

All parts of the form must be completed by the vendor and returned to Ohio Shared Services. The information must be legible.

SECTION 1 – PLEASE SPECIFY TYPE OF ACTION

NEW (W-9 OR W-8ECI FORM ATTACHED)

CHANGE OF CONTACT PERSON/INFORMATON

ADDITIONAL ADDRESS (PLEASE PROVIDE COPY OF INVOICE OR LETTER OF EXPLANATION)

CHANGE OF ADDRESS – ENTER OLD ADDRESS

CHANGE OF TIN (NEW W-9 AND LETTER OF EXPLANATION OF CHANGE, WHICH INCLUDES OLD TIN, IS REQUIRED)

CHANGE OF NAME (NEW W-9 AND LETTER OF EXPLANATION OF CHANGE IS REQUIRED)

CHANGE OF PAY TERMS

CHANGE OF PO DISPATCH METHOD

OTHER_____________________________________

SECTION 2 – PLEASE PROVIDE VENDOR INFORMATION

LEGAL BUSINESS OR INDIVIDUAL NAME: (MUST MATCH W-9 OR W-8ECI FORM)

BUSINESS NAME, TRADE NAME, DOING BUSINESS AS: (IF DIFFERENT THAN ABOVE)

FEDERAL TAX ID (TIN), EMPLOYER ID (EIN) OR SOCIAL SECURITY NUMBER (REQUIRED):

BUSINESS ENTITY: (IF A SOLE PROPRIETOR, THE INDIVIDUAL’S NAME MUST APPEAR IN LEGAL BUSINESS NAME) CHECK ONE:

INDIVIDUAL/SOLE PROPRIETOR

CORPORATION

S CORPORATION

PARTNERSHIP

TRUST/ESTATE

LIMITED LIABILITY COMPANY CIRCLE THE TAX CLASSIFICATION (C=CORPORATION, S= S CORPORATION, P=PARTNERSHIP) ______________

OTHER (PLEASE EXPLAIN)

SECTION 3 – PLEASE PROVIDE COMPLETE ADDRESS 1 (IF MORE THAN 2 ADDRESSES, INCLUDE A SEPARATE SHEET)

ADDRESS:

CITY:

STATE:

COUNTY:

ZIP CODE:

SECTION 4 – PLEASE PROVIDE COMPLETE ADDRESS 2

ADDRESS:

COUNTY:

CITY:

STATE:

ZIP CODE:

OBM-5657

05/02/2011

SECTION 5 – CONTACT INFORMATION AND PERSON TO RECEIVE PURCHASE ORDER

NAME:

WEBSITE:

PHONE:

FAX:

E-MAIL:

SECTION 6 - STRATEGIC SOURCING CONTACT INFO (PERSON TO RECEIVE E-MAIL NOTICE OF BID EVENTS)

THE USER ID & PASSWORD TO COMPLETE STRATEGIC SOURCING REGISTRATION WILL BE SENT TO E-MAIL ADDRESS BELOW.

NAME::

E-MAIL:

PHONE NUMBER:

SECTION 7 – IS YOUR BUSINESS CURRENTY CERTIFIED AS? (PLEASE CHECK)

MBE (MINORITY BUSINESS ENTERPRISE)

EDGE (ENCOURAGING DIVERSITY, GROWTH, & EQUITY)

N/A

SECTION 8 – PAYMENT TERMS (PLEASE CHECK ONE, OTHERWISE NET 30 WILL BE APPLIED BY DEFAULT)

2/10 NET 30

NET 30

NET 45

NET 60

NET 90

SECTION 9 – PURCHASE ORDER DISTRIBUTION-OTHER THAN USPS MAIL (NOTE: APPLICABLE FOR VENDORS THAT RECEIVE PO ONLY (INPUT E-MAIL ADDRESS OR FAX NUMBER BELOW)

E-MAIL OR FAX:

SECTION 10 – PLEASE SIGN AND DATE

PRINT NAME:

 

 

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE:

SECTION 11 – STATE OF OHIO AGENCY CONTACT INFORMATION (AGENCY WHERE GOODS OR SERVICES ARE DELIVERED)

AGENCY NAME:

E-MAIL:

PHONE NUMBER:

COMMENTS:

Note: This document does contain sensitive information. Sending via non-secure channels, including e-mail and fax can be a potential security risk.

 

 

 

 

SUBMIT FORM TO:

QUESTIONS? PLEASE CONTACT:

Mail:

Ohio Shared Services

Phone: 1

(877) OHIO-SS1 (1-877-644-6771)

 

P.O. Box 182880 Cols., OH 43218-2880

1

(614) 338-4781

Fax:

(614) 485-1052

E-mail: vendor@ohio.gov

E-mail:

vendor@ohio.gov

 

 

 

 

 

 

OBM-5657

 

 

REV. 02/15/2011

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