Employee Vendor Requirements Form

EMPLOYEE VENDOR REQUIREMENTS FORM

Employee Name:   Employee ID:

Personal Information

Position / Request Information

Requested Start Date:   Estimated Annual Cost / Salary:

Vendor Information

Vendor Tax Identification Number:   DUNS / Vendor ID (if applicable):

Vendor Entity Type / Classification

Individual / Sole Proprietor    Corporation    Limited Liability Company    Partnership

Is subcontracting permitted under this engagement?   Is a purchase order required to initiate payment?

Required Documentation Checklist

The following documents must be provided prior to vendor activation. Check items that are provided or will be provided within requested timeframe.

Tax identification documentation supplied
Business license or registration supplied
Certificate of Insurance (General Liability) supplied
Workers' Compensation evidence supplied (if applicable)
Professional / Errors & Omissions insurance supplied (if applicable)
Background check consent signed or to be signed

Compliance, Confidentiality, and Security

Vendor agrees to comply with all applicable company policies regarding confidentiality, data handling and privacy. Where vendor will handle sensitive data, the vendor must enter into a separate confidentiality or data processing agreement as required by the company.

Vendor will maintain appropriate administrative, technical and physical safeguards to protect any company data it receives or processes. Vendor will immediately notify company of any data breach affecting company data.

Confidentiality Agreement Acknowledgement: I acknowledge and agree to comply with confidentiality obligations.

Background Check Authorization: I authorize the company to conduct background checks and employment verifications as necessary for vendor approval.

Employment History (Most Recent)

Dates Employed:   Reason for Leaving:

Dates Employed:   Reason for Leaving:

Education

Graduation Date:

Professional References (3)

Legal Disclosures

At-Will Employment Acknowledgement: If this engagement relates to employment, the employee acknowledges that employment with the company is at-will unless specifically set forth in a separate written agreement signed by an authorized representative of the company. Nothing in this Vendor Requirements Form alters that relationship.

Equal Opportunity Statement: The company provides equal employment and contracting opportunities to all qualified persons without regard to protected class status. Selection of vendors and contractors will be conducted consistent with applicable non-discrimination obligations.

Applicant / Vendor Certification and Authorization

I certify that the information provided in this Employee Vendor Requirements Form is true, complete, and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may result in disqualification of the vendor or termination of employment or engagement.

I authorize the company and its agents to contact my prior employers and references, and to obtain criminal, credit, or other background checks where permitted by law and required for vendor approval. I authorize all persons and entities to release such information to the company.

Indemnification Acknowledgement: Where vendor status applies, the vendor acknowledges responsibility for defense and indemnification of the company for claims arising from vendor performance except to the extent caused by company negligence.

By signing below I certify the foregoing and acknowledge that additional documentation and formal agreements may be required before services commence.

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