Vendor Registration Application Form

VENDOR REGISTRATION APPLICATION FORM

WHEREAS

WHEREAS, Vendor submits this application to become an approved supplier of goods and/or services to the Company and to establish the terms under which procurement, payment, and other contractual matters will be conducted; and

WHEREAS, the Company requires completed vendor information, certifications, insurance evidence, and agreement to standard business terms prior to authorization; and

NOW, THEREFORE, Vendor provides the information and agrees to the terms set forth in this application and the attached terms and conditions below.

VENDOR INFORMATION

Corporation LLC Partnership Individual / Sole Proprietor Other

BUSINESS PROFILE & CAPABILITIES

BANKING & PAYMENT INFORMATION

Check ACH / Electronic Transfer Wire Transfer

INSURANCE & COMPLIANCE

Vendor certifies that it maintains insurance coverage as required by the Company and applicable law and will provide certificates of insurance upon request. Check all that apply:

General Liability Professional Liability Workers' Compensation Commercial Auto

REFERENCES

SCOPE OF WORK

Describe the goods and/or services the Vendor provides under this registration, including typical deliverables, performance standards, and any service levels the Vendor agrees to meet.

PAYMENT TERMS

Contract/Order Value (if known): $

Standard Payment Terms: Net days from receipt of a correct invoice.

Late Payment Fee: Interest at on overdue balances or the maximum permitted by law, whichever is lower.

TERM AND TERMINATION

Registration Effective Date:

Registration Expiration Date (if applicable):

Either party may terminate a purchase order or this registration for cause upon written notice specifying the breach and providing days to cure. For convenience, either party may terminate upon days' prior written notice.

CONFIDENTIALITY

Vendor and Company acknowledge that, in the course of performance, they may receive Confidential Information. Each party shall: (a) hold Confidential Information in strict confidence; (b) not disclose it except to employees, agents, or subcontractors with a need to know who are bound to maintain confidentiality; and (c) use Confidential Information solely for the purposes of performing under applicable orders. Confidentiality obligations will survive termination for years, except as required by law.

GOVERNING LAW; ENTIRE AGREEMENT

This application and any resulting purchase order or agreement shall be governed by the laws of the State of without regard to conflict of laws principles. This application, together with any referenced purchase orders and written terms mutually executed by the parties, constitutes the entire agreement between the parties concerning the subject matter and supersedes all prior proposals, negotiations, and representations, whether written or oral.

REPRESENTATIONS, WARRANTIES & INDEMNITY

Vendor represents and warrants that: (a) all information provided herein is true, complete, and accurate; (b) Vendor is authorized to perform the goods and services described and holds all necessary licenses; and (c) Vendor will comply with all applicable laws. Vendor shall indemnify, defend and hold harmless the Company from and against all claims, liabilities, losses, damages, costs and expenses arising from Vendor's performance, breach of these representations, or negligence.

ACKNOWLEDGMENT & CERTIFICATION

By signing below, the undersigned certifies under penalty of perjury that the information provided in this Vendor Registration Application Form is true, accurate, and complete; that Vendor will promptly notify the Company of any material changes; and that Vendor accepts the business terms, payment provisions, insurance and indemnity obligations described herein.

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