Vendor Information

In an effort to update and maintain our vendor records we are requesting the following be completed.

In order to comply with IRS regulations, Periscope Inc., is required to report payments for rents, royalties and compensation for certain types of services to individuals and businesses on IRS form 1099.

Our diversity request form is an initiative designed to develop mutually beneficial relationships that reflect our multicultural marketplace for Periscope and our clients.

By checking this box and proceeding to the next page of this form, you acknowledge that you have read and agree to the terms of the Periscope (Quad) Vendor Code of Conduct located here: Periscope (Quad) Vendor Code of Conduct

I have read and agree to the required terms above.

Yes

New Vendor or Information Update

New VendorUpdated Information

VENDOR CLASSIFICATION / IRS INFORMATION

Name (as shown on Income Tax Return)

Business name/disregarded entity name, if different from above

Corporate Address (as shown on Income Tax Return) Street Address

City

State/Province

Zip Code/Postal Code

Submit with FEIN, SSN or TIN

FEINSSNTIN

FEIN

TIN

SSN

Check appropriate box for federal tax classification. Note: For a single-member LLC that is disregarded, do not check LLC; check the appropriate box below for the tax classification of the single-member owner.

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/Estate

Limited Liability Company

Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Exempt payee code (if any)

Exemption from FACTA reporting code (if any)

CONTACT / PAYMENT INFORMATION

Accounts Payable Contact Name

AP Contact Phone

AP Contact Email

Payment Remittance Address

Preferred Method of Payment

CheckEFTCredit Card

Banking Institution Name:

Name on Account: (As shown on bank records)

Banking Institution City:

Bank ABA/Routing Number:

Bank Account Number:

BUSINESS DEMOGRAPHICS

Industry & Type of Business:

Year Established

Number of Employees

Service Area

Annual Revenue (past 3 years)

Are you a diverse business? (Please see definition below.)

Diverse Business - For purpose of this program, Periscope considers to be diverse if they are at least 51% owned, operated and controlled by individuals who fall into one or more of the following categories:

1. Minority Business Enterprise (MBE) with the following subcategories: Asian-Indian, Asian-Pacific, Black, Hispanic, Native American

2. Women Owned Business Enterprise (WBE)

3. Veteran Owned Business Enterprise (VET)

4. Service Disabled Veteran Business (SDV)

5. Disabled Owner Business

6. Small Business Enterprise (SBE)

7. Lesbian, Gay, Bisexual, and/or Transgender (LGBT)

In order to be included in our Vendor Diversity program, we require firms to become certified by one of the following agencies: NMSDC, WBENC, NWBOC, NGLCC, SBA, Federal/State or City certifying organization.

Diversity Category (select one or more as applicable)

MBE Category

Certification Type

Please enter your Certification number

Attach your certification form

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because:

(a) I am exempt from backup withholding, or
(b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or
(c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must check the box below if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN.

I have been notified by the IRS that I am currently subject to backup withholding because I have failed to report all interest and dividends on my tax return.

Please enter your name (Person filling out this form)

By checking this box you agree that all of the information you provided in this form is true and accurate.