LHU Vendor Registration Form

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401 N. Fairview Street
Lock Haven, PA 17745
570-484-2011
1-800-332 8900 in PA

Apply to LHU

Vendor Registration Form

Required FIELDS are Preceded by an Asterisk ( * )
Please do not use commas when filling out this form.

Name

Legal Name:
*

Legal Name Continued and/or Trading/Doing Business As:
*

Address

Enter Street Address 1:
*

Street Address 2:

OR PO Box Number:

City:
*

State/Province:                         Zip Code: xxxxx-xxxx
    *

Provide Pennsylvania County for Address:

Contact Information

Contact Name:
*

Email Address:
*

Phone: xxx-xxx-xxxx:                                     Extension:
*

Fax: xxx-xxx-xxxx:
*

* Taxpayer Identification Number (Do not enter hyphens or spaces)

Federal EIN must be in the form: 999999999.
Please do not include hyphens or spaces.

Employer Identification Number (EIN) or Social Security Number (SSN):
*

General information on supplies and/or services that your
company/organization provides:

If sending electronic attachments, send them to: khibbler@lhup.edu

Ownership Classification: (check only one) *

BBE: Black Business Enterprise
DAG: Disadvantaged Group
MBE: Minority Business Enterprise
MJR: Majority Vendor
PHB: PA Industries Blind & Handicap
WBE: Women Owned Business Enterprise

Lock Haven University
Office of Procurement
East Campus Complex
301 West Church Street, Room J211
Lock Haven, PA 17745
Fax: (570)484-2844

By completing and submitting this Registration Form, you certify that: (i) you are authorized to submit this Form for, or on behalf of, the person or entity named in the Form; and, (ii) all of the information on or in this Form is true and correct to the best of your knowledge, information, and belief. Any false statements made by you on or in this Non-Procurement Vendor Registration Form are subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

Updated 11/24/2009

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