HR Supplier Details Request

HR Supplier Details Request

This form collects detailed corporate, contact, compliance and payment information required to establish a supplier/vendor record with the Human Resources department. Complete every applicable field and provide supporting documentation upon request. Incomplete submissions may delay onboarding and payment.

Supplier Company Details

Business Structure: Corporation LLC Partnership Sole Proprietor Other:

Primary Contact — Personal & Position Information

Reporting Manager (at supplier):   Start Date in Current Role:

Employment History — Primary Contact (Most Recent)

Employment History — Prior Employer

Education

Professional References (3)

Services, Account Setup & Project Details

Service Categories (select all that apply): Background Screening Training / Development Benefits Administration Payroll Services HR Consulting Software / Licensing Other:

Payment & Banking Information

Preferred Payment Method: ACH Check Wire

Compliance, Insurance & Data Protection

Insurance Coverage — Indicate coverage and provide policy details where applicable:

Yes No Insurer: Policy #: Limit:

Yes No Insurer: Policy #:

Yes No Insurer: Policy #: Limit:

Access to Employee Data: Yes No If yes, supplier agrees to comply with applicable privacy and data protection obligations described below.

Legal Disclosures, Representations & Certifications

Representations and Warranties: The supplier represents and warrants that it is duly organized and in good standing under the laws of its jurisdiction, has authority to enter into this request response, and that all information supplied herein is true, complete and correct. The supplier will promptly notify the Human Resources department in writing of any material change in the information provided.

Confidentiality and Data Protection: Where supplier will receive, process, or otherwise access personal employee data, supplier certifies that it will implement and maintain appropriate technical, administrative and organizational measures to protect such data, will process data only for the stated service purposes, and will not disclose personal data except as permitted by law or by written authorization. Supplier will notify the company without undue delay of any security breach affecting company data.

Compliance with Laws: Supplier will comply with all applicable federal, state and local laws, regulations and ordinances in the performance of services, including labor and employment laws, anti-discrimination laws, and applicable privacy statutes.

Indemnification: Supplier agrees to indemnify, defend and hold harmless the company, its officers, directors and employees from and against any and all claims, liabilities, losses, damages and expenses (including reasonable attorneys' fees) arising from supplier's negligence, willful misconduct, or breach of these representations.

Conflict of Interest: Supplier certifies that, to the best of its knowledge, there exists no conflict of interest that would impair supplier's ability to provide unbiased services and that it will disclose to Human Resources any actual or potential conflict of interest that may arise during the course of the engagement.

Authorization for Background Checks: Supplier authorizes the company and its agents to conduct background checks and verify employment history for any supplier personnel who will perform services that require access to company facilities, systems, or employee personal information. Check to indicate consent: Supplier consents to background checks

Certification of Accuracy: I certify under penalty of perjury that the information provided on this form is true, correct and complete to the best of my knowledge. I acknowledge that providing materially false information may result in termination of supplier relationship and recovery of damages.

Attachments & Additional Documentation

Federal Tax Form Certificate of Insurance ACH Authorization Signed Contract / SOW Other:

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