HR Vendor Information Request

HR Vendor Information Request

Please complete this form in full to initiate vendor setup, compliance review, and contracting with Human Resources. Incomplete responses may delay onboarding. Provide the legal entity name that will appear on contractual documents and invoices: Vendor Legal Name:

Business & Contact Information

Entity Type: Corporation LLC Sole Proprietor Partnership Other:

Services & Engagement Details

Company Background & Insurance

Insurance coverage: Indicate whether the vendor maintains the following coverages and attach certificates upon request.

General Liability — Policy Limit:

Workers' Compensation — State Coverage:

Professional Liability / E&O — Policy Limit:

Banking / Remittance Information

ACH / Wire details (if required for payment): Bank Name: Routing #: Account #:

Employment History (Primary Contact)

Provide two most recent employers for the primary contact. Employer 1:

Employer 2:

Education (Primary Contact)

References

Provide three professional references familiar with the vendor's performance on similar engagements.

Legal Disclosures & Certifications

At-Will Employment Statement: Where individuals provided by the vendor perform work for the organization, those individuals are engaged by the vendor and the vendor acknowledges that any direct-hire offer or engagement arranged by the organization with a vendor-supplied individual may be on an at-will basis unless otherwise agreed in a written employment agreement.

Equal Employment Opportunity: Vendor affirms it is an equal opportunity employer and will comply with all applicable anti-discrimination and equal employment laws in the performance of services. Vendor agrees not to discriminate in hiring, promotion, termination, compensation or other employment terms and conditions.

Background Checks and Verification: Vendor hereby authorizes the organization and its agents to verify information submitted on this form, to contact references, and to obtain background checks on the vendor's personnel assigned to the engagement as permitted by law. Vendor will ensure that all personnel assigned to perform services consent to such checks.

Debarment and Suspension: Vendor certifies that it and its principals are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in transactions by any federal, state, or local governmental department or agency.

I certify that all information provided in this form is true, complete and correct to the best of my knowledge, and understand that knowingly providing false information may result in termination of any contract and potential indemnification obligations.

I authorize the organization to contact references and prior employers listed for purposes of evaluating this vendor application and verifying qualifications.

I agree that assigned personnel will submit to background checks as required and that necessary releases have been or will be obtained from those personnel.

Additional Information

Applicant Certification

I certify under penalty of perjury that the information contained in this HR Vendor Information Request is true, accurate, and complete. I understand that submission of false or misleading information may result in denial of vendor status, termination of agreements, or other legal remedies. I authorize the organization to rely upon the representations made in this form in deciding whether to engage the vendor, and I agree to promptly notify the organization in writing of any material change to any information provided herein.

By signing below, the undersigned warrants authority to bind the vendor to the certifications and authorizations contained in this form.

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