ICMA Vendor Application

ICMA Vendor Application
Please complete all required fields (*) in this form. If you have any questions, please reach out to accountspayable@icma.org
Vendor Name:*
Contact Name:*
FAX:
Email:*
Type of U.S. Taxpayer Identification Number (TIN)*

EINSSNOther
Enter the EIN:
Enter the SSN:
Please explain Other:
Is the Company Address in the USA?*

YesNo
Company Address - USA

Street Address

Street Address Line 2

CityState

Zip Code
Phone
Please enter a valid phone number.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone

Country CodeArea CodePhone Number
Invoice Remittance Address
Same as Company Address?*

YesNo
Is the Remittance Address in the USA?

YesNo
Invoice Remittance Address - USA

Street Address

Street Address Line 2

CityState

Zip Code
Invoice Remittance Address - Non USA

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please Check All that Apply to your Company

CorporationPartnershipMedical CorporationNon-ResidentSole Proprietorship/Independent ContractorGovernment EntityTax Exempt Organization under IRS (501) Rules1099American Indian OwnedVeteran Owned BusinessHUB Zone Firm*Service Disabled Veteran OwnedSmall BusinessDisabledLarge Business (500+)Nonprofit OrganizationDisadvantaged Business**ShelteredWoman Owned BusinessForeign SupplierLimited Liability CompanyHistorically Black College/University
* FAR Clause 52.219-1(d) (2) Under 15 U.S.C 645(d), any person who misrepresents a firm’s status as a small, HUBZone small, small disadvantaged, or women-owned small business concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act or any other provision of Federal law that specifically references sections 8(d) for a definition of program eligibility, shall: (i) Be punished by imposition of fine, imprisonment or both; (ii) Be subject to administrative remedies, including suspension and debarment and (iii) Be ineligible for participation in programs conducted under the authority of the Act.

**Hub Zone and Small Disadvantaged Business must provide a copy of their certificate with this form.
Please verify that you are human*
FCANotifyEmail
DateSubmitted

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ICMA Vendor Application

Invoice Remittance Address