Vendor Information and Certification

2. About This Form
   The City of Edina's Finance Department requires those receiving payment from the City to provide a W9 and up-to-date financial contact/Remit To information. <br><br> Use this form to:<br> - Submit a copy of your W9<br> - Update contact information for those authorized to provide banking information and change the Remit To address <br> - Update your Remit To information<br> - Provide any other contact information such as sales, accounts receivable, etc.<br> - Provide proof of certifications<br> <br> DO NOT INCLUDE bank routing or financial account numbers with this form.

   The City of Edina's Finance Department requires those receiving payment from the City to provide a W9 and up-to-date financial contact/Remit To information.
   
   Use this form to:
   - Submit a copy of your W9
   - Update contact information for those authorized to provide banking information and change the Remit To address
   - Update your Remit To information
   - Provide any other contact information such as sales, accounts receivable, etc.
   - Provide proof of certifications
   
   DO NOT INCLUDE bank routing or financial account numbers with this form.

4. Provide W9
   We will pull business information off of your W9. Please complete the additional information on this form as applicable.

   We will pull business information off of your W9. Please complete the additional information on this form as applicable.

6. Upload W9*

   Most common file types accepted including JPG, PDF, DOC, DOCX, TIF, etc.

10. Financial Contact
    We will contact you separately for banking information. <br><br> Please list the proper contact for banking/payment receipt information who has the authority to change the remit address.

    We will contact you separately for banking information.
    
    Please list the proper contact for banking/payment receipt information who has the authority to change the remit address.

12. Financial Contact Name*

13. Email Address*

15. Address*

17. City*

18. State*

19. Zip Code*

21. Phone Number*

23. Electronic Payments*

    Are you interested in payments being made to your business electronically?

    1. Yes
    2. No
27. Remit To Information*

    Is the Remit To the same information as listed on your W9?

    1. Yes
    2. No
29. Remit To Name*

30. Email Address*

32. Address*

34. City*

35. State*

36. Zip Code*

38. Phone Number*

42. Other Contacts

44. Accounts Receivable Contact*

    Is there an A/R contact other than the person(s) already listed on this form?

    1. Yes
    2. No
46. Name*

47. Email Address*

49. Address*

51. City*

52. State*

53. Zip Code*

55. Phone Number*

57. Other Contact*

    Is there another contact you would like to provide, such as in sales or customer service, that would be a contact for financial information?

    1. Yes
    2. No
59. Name*

60. Email Address*

62. Address*

64. City*

65. State*

66. Zip Code*

68. Phone Number*

72. Certifications
    Please check any applicable certifications, supply last certification date and upload a copy of your certifications obtained through the Minnesota United Certification Program, the Office of State Procurement (OSP) or the Central Certification Program (CERT).

    Please check any applicable certifications, supply last certification date and upload a copy of your certifications obtained through the Minnesota United Certification Program, the Office of State Procurement (OSP) or the Central Certification Program (CERT).

74. Certification Type

    Check all that apply

    1. Minority-Owned Business
    2. Women-Owned Business
    3. Veteran-Owned Business

    1. Substantial Physical Disability
    2. Economically Disadvantaged Area
    3. Other
76. Explain Other*

    If you marked "Other" certification type, please provide a brief explanation and upload proof in the upload section below.

78. Last Certification Date

    Please list last certification date for any of the certifications you checked.

80. Upload Certificate

81. Upload Certificate

    Use if you have more than one

83. Questions?
    For questions regarding this form or the vendor payment process, contact Accounting Clerk Lonnia Jefferson at 952-825-0411 or ljefferson@EdinaMN.gov.

    For questions regarding this form or the vendor payment process, contact Accounting Clerk Lonnia Jefferson at 952-825-0411 or ljefferson@EdinaMN.gov.

85. Public Records Notice*

    Some information you provide on this form, such as your business' certification type, is considered public record and would be released upon request. W9s and financial information are not public records and would not be released.

    1. I have read and understand the public records notice.
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87. Submit

* indicates a required field