Supplier Approval Request Form

SUPPLIER APPROVAL REQUEST FORM

Request Information

Request Number:    Date of Request:

Supplier Details

Corporation    LLC    Sole Proprietorship    Partnership    Non-Profit    Foreign Entity

Scope of Goods or Services

Provide a detailed description of the goods or services for which supplier approval is requested. Include deliverables, performance standards, and service levels.

Payment Terms (Administrative)

Set forth the financial terms applicable if supplier is approved. Complete monetary fields and select schedule.

Default Amount or Rate (if applicable):    Schedule:

Compliance & Attachments

Required documentation provided with this request:

W-9 or foreign equivalent    Certificate of Insurance    Master Service Agreement / PO    Vendor Code of Conduct acknowledgement

Risk Assessment

Initial risk rating (select one):    Low    Medium    High

Supplier Approval Agreement (Contractual Clauses)

WHEREAS, Requesting Party (Company): seeks to engage Supplier to provide the goods and services described in the Scope of Goods or Services above; and

WHEREAS, Supplier: represents that it has the qualifications, resources and legal authority to supply such goods and services; and

NOW, THEREFORE, in consideration of the mutual promises contained herein, the parties agree as follows:

1. Scope of Work

Supplier shall perform and deliver the goods and/or services as described in the Scope of Goods or Services section above in accordance with the performance standards and timelines set forth therein. Any material change to the scope must be documented in writing and signed by authorized representatives of both parties.

2. Payment Terms

Payment shall be made in accordance with the Payment Terms indicated above. Invoices presented by Supplier must reference this request number and comply with Company invoicing requirements. Late payments shall incur the Late Payment Fee specified above, calculated from the due date until payment in full. Any discounts, holdbacks or milestone payments must be set forth in a separate schedule attached hereto.

3. Term and Termination

This approval and any resulting engagement commences on and expires on unless earlier terminated in accordance with this clause. Either party may terminate for convenience upon days' prior written notice. Termination for cause may be effected immediately upon material breach that remains uncured following reasonable notice as required by law or the parties' agreement.

4. Confidentiality

Each party shall protect confidential information disclosed by the other party and shall not use or disclose such information except as required to perform obligations under this approval or as required by law. Confidential information does not include information that is publicly available through no fault of the receiving party or independently developed without use of the disclosing party's confidential material. Obligations of confidentiality survive termination for a period of three (3) years unless otherwise agreed in writing.

5. Governing Law

This approval and any disputes arising out of or relating to it shall be governed by the laws of the state of without regard to conflict of laws principles.

6. Entire Agreement

This Supplier Approval Request Form, together with any attachments and referenced documents executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior or contemporaneous understandings, proposals or agreements, whether written or oral. Any amendment must be executed in writing by authorized representatives of both parties.

Certification

By submitting this Supplier Approval Request Form the Requestor certifies that, to the best of their knowledge, the information provided is true, accurate and complete; that the supplier is not debarred or suspended from doing business with government entities where applicable; and that any required approvals or budgets have been obtained prior to submission.

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