Form Name:Master SupplierInvestigator Name:Jay TrehanClick here to view a sample form. Your Full Name*Email Address* Phone*Preferred form of contact Email PhoneNew, Update, or Inactive? New Update InactiveSubmitter InformationSubmitted by:Department / AgencyLucas County Supplier NumberPhoneExtEmail Yes / No01 Is Supplier a medical/heath care supplier or providing medical services? Yes No02 Is Supplier an attorney providing legal services? Yes No03 Is Supplier an individual / partnership / LLC? Yes No04 Is Supplier an employee? Yes No05 Is Supplier tax exempt? Yes No06 Is this foster care payment? Yes No07 Is Supplier incorporated? Yes No08 Is this child support or garnishment? Yes No09 Is this for reimbursement? Yes No10 Is this for services? Yes NoRemit AddressSupplier NameDoing Business as (DBA) (If Applicable)Street / P.O. BoxCityStateZipContact NamePhone NumberFaxEmail AddressIssuing Information Issue Check to DBA Issue Check to Supplier Name Issue 1099 to DBA Issue 1099 to Supplier NameOrder AddressSupplier NameDoing Business as (DBA) (If Applicable)Street / P.O. BoxCityStateZipContact NamePhone NumberFaxEmail Address
