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NEW VENDOR REQUEST FORM


Vendor Data
Vendor Name:


Vendor Remit To Address:


Vendor Phone:


Vendor Fax:


Vendor Web Address:


Dun & Bradstreet Number:


Primary Contact
Primary Contact Name:


Primary Contact Position:


Primary Contact Address:


Primary Contact Phone:


Primary Contact Fax:


Primary Contact E-mail Address:


Order E-mail Address*:

*Valid e-mail required. All purchase orders are e-mailed to this address.

Confirm fax of a Form W-9 will be faxed to 724-658-5138, Attn: IPEC Purchasing Department?
 Yes
 No

Your IPEC Contact's Name:


Your IPEC Contact's E-mail:

IPEC's standard e-mail format is first letter of first name, full last name then @ipec.com. For example, Joe Smith would be jsmith@ipec.com