* Firm Name:
(Name as listed on W-9)
* Address:
* City:
* State:
* ZIP Code:
* Telephone:
* Email:
(Please note that the e mail address must be that of the authorized Company e-mail.NOTE: Only company addresses will be allowed. E-mail or physical addresses of sales representatives are not acceptable and will not be allowed)

Address for Payment, if different from above:
ZIP Code:

Authorized Company Officer & Title:
Authorized Sales Representative:

Is your company a minority-owned or disadvantaged business as defined below?
A minority business is defined as a business that is both owned and controlled by minorities and/or women. Minorities and/or women must own at least 51% of the business and control its management and daily operations. Minorities include Black, Women, American Indians, Alaskan Natives, Asian American, Hispanics and members of other groups determined to be economically or socially disadvantaged by the Small Business Administration under Section A of the Small Business Act as amended (15 USC 637 a). HUB Zone business as determined by the Small Business Administration is a small business located within a HUB Zone.
If yes, please select the category that properly defines your minority status:
If others specify:
Woman Owned:
Small Business:
Hub Zone:

Uniform Certification Agency Certification Number:

Local Business
(Requires a Shelby County Business License that has been held for the past 6 months)
* Organization of Business:

Are you a registered vendor on eSchoolMall?
Are you currently an employee or retiree of the Memphis City Schools or Shelby County Schools District?
Have you ever been an employee of the Memphis City Schools or Shelby County Schools District?
If yes please list your last date of employment with the Memphis City Schools or Shelby County Schools District:

Please add NIGP Codes that best describe your product or service.
Comm Code 1:
Comm Code 2:
Comm Code 3:
Comm Code 4:
Comm Code 5:
Comm Code 6:
* Attachments:
Please attach your completed W-9 form (International vendors need to attach their completed W-8BEN form). If you do not already have a completed W-9 or W-8BEN (International vendors) form, please download it from and complete the form before adding as an attachment.


Conflict of Interest: By submitting this signed form, you are declaring that no Shelby County Schools Unified District Board Commissioner or employee has a financial or beneficial interest in this firm. Vendor also agrees to extend credit to Shelby County Schools Unified District, without requiring a credit application, to fulfill any purchase orders and/or contractual obligations that may occur. Vendor's bid maybe rejected should a credit application be required. NOTE: Each vendor is responsible for notifying the Shelby County Schools Unified District Purchasing Department of any future business name, address, telephone number, Email, or any other vendor information change.
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