Dear Vendor,

In order to set you up as a new vendor and as part of our business practice and compliance with IRS regulations,we are requesting that you provide us with all the information listed below:

* W-9 FORM
The Internal Revenue Service Regulations require that certain payees be provided with Annual Information Returns (form 1099 MISC, 1099 INT) for payments made to them during the past calendar year. As of 1993, Federal Law requires that we withhold 31% on each invoice for which we have not received a Taxpayer Identification Number (TIN).

To comply with these regulations, we need the enclosed W-9 form to be filled out completely to determine if you should be provided with a form 1099MISC on an annual basis. It is important that you complete this form even if you have sent the information about your TIN. If you are exempt from withholding, please be sure to mark the form to indicate as much.



* RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT



Please sign and return this agreement.

* INSURANCE CERTIFICATE
Please contact your insurance company and have them add Bodega Latina Corporation as an additional insured in your liability insurance relating to product liability and forward us a copy. If your company representatives do any physical labor in our store (i.e. Product Displays), then also provide us insurance certificate for Workers Compensation with Bodega Latina Corporation as an additional insured.

BUSINESS AND CONTACT INFORMATION
 
Business Name:
Contact Title:
Contact Name:
Contact E-Mail:
Department:
Telephone Number:
Telephone Extension:
Fax Number:
Address:
City:
State:
Zip Code:
Country:
 
REMIT TO ADDRESS
Address:
City:
State:
Zip Code:
Country:

Agree that all information provided is true and correct: