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Step One

City of Jacksonville Vendor Application
Vendors, please complete entire application.
Vendor Name
Does business have less than three employees?*
1. Yes
1. No
Payment Information
Please fill out the following payment information.
Contact Name
Street Address
City
State
Zip Code
Phone Number
Fax Number
Order Information
Please fill out the following order information.
Contact Name
Street Address
City
State
Zip Code
Phone Number
Fax Number
Are You a certified Minority Business Enterprise?*
1. Yes
2. No
Please check on e of the following that best describes your business:
1. African American
2. American Indian
3. Asian American
4. Female
5. Hispanic
6. Disabled as defined in GS 168-1 or GS 168A-3
7. Non-Profit Work Center for Blind; Severely Disabled as defined in GS143-4B
8. Socially and Economically Disadvantaged as defined in 15 USC 637
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Vendor Name
Phone Number
Please select one of the following:
1. First time request for automatic payment
2. Request to change automatic payment information
Bank Account Information
I hereby authorize the City of Jacksonville to initiate deposits to the checking account described below:
1. Yes
2. No
Banking Institution
Street Address
City
State
Zip Code
Bank Routing Number
Checking Account Number
Title
Phone Number
Deposit Notification Information
I hereby authorize the following individual to receive notification via email of payment details of all funds deposited to the above account:
Name
Email
Terms
This authority will remain in full force and effect until the City of Jacksonville has received written notification of discontinuation and in such manner as to afford the City of Jacksonville and Depository a reasonable opportunity to act on it.
I agree to the terms stated above:
1. Yes
2. No
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