Form Name:

Master Supplier

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Your Full Name*
Email Address*
Phone*
Preferred form of contact
- Email
- Phone
New, Update, or Inactive?
- New
- Update
- Inactive
Submitter Information
Submitted by:
Department / Agency
Lucas County Supplier Number
Phone
Ext
Email
Yes / No
01 Is Supplier a medical/heath care supplier or providing medical services?
- Yes
- No
02 Is Supplier an attorney providing legal services?
- Yes
- No
03 Is Supplier an individual / partnership / LLC?
- Yes
- No
04 Is Supplier an employee?
- Yes
- No
05 Is Supplier tax exempt?
- Yes
- No
06 Is this foster care payment?
- Yes
- No
07 Is Supplier incorporated?
- Yes
- No
08 Is this child support or garnishment?
- Yes
- No
09 Is this for reimbursement?
- Yes
- No
10 Is this for services?
- Yes
- No
Remit Address
Supplier Name
Doing Business as (DBA) (If Applicable)
Street / P.O. Box
City
State
Zip
Contact Name
Phone Number
Fax
Email Address
Issuing Information
- Issue Check to DBA
- Issue Check to Supplier Name
- Issue 1099 to DBA
- Issue 1099 to Supplier Name
Order Address
Supplier Name
Doing Business as (DBA) (If Applicable)
Street / P.O. Box
City
State
Zip
Contact Name
Phone Number
Fax
Email Address

2595 Arlington Ave, 2^nd Floor
Toledo, OH 43614

Hours:
Monday-Friday, 8:30 a.m. – 4 p.m.*
*Closed on all federal holidays

Phone:
(419) 213-6090