HR Supplier Intake Form

HR SUPPLIER INTAKE FORM

Supplier Name:    DBA:

Supplier Legal & Contact Information

Corporation   LLC   Sole Proprietorship   Partnership

Government   Non-Profit   Other:

Primary Contacts

Title:    Phone:    Email:

Phone:    Email:

Services, Scope & Categories

Contingent Labor   Professional Services   Temporary Staffing
Payroll Services   Training & Development   Background Screening   Other:

Pricing, Billing & Banking

Net 15   Net 30   Net 45   Net 60   Other:

Account Number:    Routing Number:    ACH Preferred:

Insurance & Compliance

General Liability Limit:    Policy Number:

Workers' Compensation Carrier:    Policy #:

Professional Liability Limit:    Policy #:

Insurance Certificate Expiration Date:    Certificate of Insurance on file:

Background Checks, Key Personnel & Qualifications

Supplier performs background checks on personnel:    Supplier authorizes client to conduct background or credential checks on assigned personnel:

Role/Title to be assigned:    Expected Start Date:    Proposed Rate:

Employment History for Primary Assigned Individual (minimum two entries)

Title:    From:    To:

Title:    From:    To:

Education

Professional References (Minimum 3)

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Legal Disclosures & Representations

Equal Opportunity: Supplier warrants that it is an equal opportunity employer and that any personnel supplied to the client shall be selected and treated in compliance with applicable anti-discrimination laws and the client's nondiscrimination policies. Supplier will not unlawfully discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other protected characteristic.

At-Will Employment Clarification: Supplier acknowledges and agrees that personnel provided to the client remain employees or contractors of Supplier and that Supplier is responsible for all employment, payroll, tax and benefit obligations of its personnel. Supplier represents that it employs and manages its workers in accordance with applicable employment laws.

Debarment and Sanctions: Supplier certifies that neither it nor any of its principals are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in government contracts or from receiving federal funds. Supplier will notify the client immediately if any such status arises.

Compliance with Laws; Anti‑Bribery: Supplier warrants that it will comply with all applicable laws, rules and regulations in the performance of services, including anti‑corruption and anti‑bribery laws. Supplier will not offer or provide anything of value to any client employee or representative in violation of law or client policy.

Required Documents Checklist (attach copies)

W-9 or equivalent tax form   Certificate of Insurance   Signed Master Service Agreement   Business License

Equal Opportunity Policy   Background Check Consent for Personnel   Other:

Authorization, Certifications & Audit Consent

Certification: I certify that all information provided in this form and accompanying documentation is true, complete and accurate to the best of my knowledge. I understand that material misrepresentation or omission may be grounds for rejection of this supplier application or termination of any engagement.

Authorization: By signing below, Supplier authorizes the client and its agents to verify any information provided herein, to contact references and prior employers, to conduct credit or background checks where permitted by law, and to obtain certificates of insurance or other verification of compliance. Supplier agrees to provide reasonable cooperation and documentation to support such verification.

Audit and Record Retention: Supplier agrees to retain payroll and personnel records related to services provided for a minimum of three years and to permit reasonable audits by the client or its authorized representatives to verify compliance with contractual obligations and applicable law.

Declarations

Conflict of Interest: Supplier declares that, to the best of its knowledge, no conflict of interest exists between Supplier and the client that would impair Supplier's duties or objectivity. If a potential conflict arises, Supplier will notify the client immediately:

Debarment Acknowledgement: Supplier confirms it is not debarred or suspended and has disclosed any relevant sanctions or investigations.

Supplier Representative Certification

I hereby certify under penalty of civil and criminal liability that I am authorized to execute this Supplier Intake Form on behalf of the Supplier named above and that the information supplied is true, accurate and complete.

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