Form Name:Master Supplier Investigator Name:Jana Oyerbides Click here to view a sample form. Your Full Name*Email Address* Phone*Preferred form of contactEmailPhoneNew, Update, or Inactive?NewUpdateInactiveSubmitter InformationSubmitted by:Department / AgencyLucas County Supplier NumberPhoneExtEmail Yes / No01 Is Supplier a medical/heath care supplier or providing medical services?YesNo02 Is Supplier an attorney providing legal services?YesNo03 Is Supplier an individual / partnership / LLC?YesNo04 Is Supplier an employee?YesNo05 Is Supplier tax exempt?YesNo06 Is this foster care payment?YesNo07 Is Supplier incorporated?YesNo08 Is this child support or garnishment?YesNo09 Is this for reimbursement?YesNo10 Is this for services?YesNoRemit 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