Instructions:

If you plan to do business with a vendor not currently listed in Procurify, please complete the form below. The Treasurer will use the information provided to create or update the vendor in AVFRD’s system.

A W-9 FORM IS REQUIRED FOR ALL NEW VENDORS.

Please allow 3 business days for the request to be completed. You will be notified by email.

When applicable, Form 1099 will be sent to the address provided on the W-9 form.

This form is for internal use only by Ashburn Volunteer Fire and Rescue Department Members and Employees

Vendor Request Form

Requester's Name(Required)

First Last

AVFRD Email(Required)

Is this a new vendor request or a vendor change request?(Required)

New Vendor Request

Vendor Change Request

Name of Entity (Line 1 of W-9)(Required)

Business Name (Line 2 of W-9)(Required)

Vendor Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vendor Telephone Number(Required)

Vendor Fax Number

Vendor Email(Required)

Enter Email Confirm Email

Vendor Contact Name(Required)

Vendor Website(Required)

Justification for new vendor request(Required)

Upload Vendor W-9

Max. file size: 200 MB.

Conflict of Interest(Required)

In accordance with the laws of the Commonwealth of Virginia and the policies of the Ashburn Volunteer Fire and Rescue Department (AVFRD), individuals submitting a request to add a new vendor must disclose any potential conflicts of interest. By checking the box below, I affirm that: I do not have a financial interest in the vendor being proposed. I am not employed by, nor do I have a family member or close associate employed by, the vendor being proposed. I have not received and will not receive any compensation, gifts, or benefits from the vendor in relation to this request. To the best of my knowledge, the vendor relationship supports the best interests of AVFRD and complies with all applicable laws and policies. I understand that any actual or perceived conflict of interest must be disclosed to AVFRD in writing.

I acknowledge and certify that the above statement is true and accurate to the best of my knowledge.

I have an actual or potential conflict of interest to disclose.

Please explain your actual or potential conflict of interest below:(Required)

Vendor Request Form

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