See Other Side of Form

Substitute W-9 Form

Legal Name: (If individual, enter last name first)

Trade Name (DBA):

Preferred Company Abbreviation: (If applicable)

Mail PURCHASE ORDERS and BIDS to: Mail PAYMENTS to:

Telephone # Fax # Toll Free # Toll Free Fax #

DUNS Number for Purchase Order location:

Complete both columns: Type of Organization: Taxpayer Identification Number: (Check only ONE) Employer Identification # Social Security #

Individual Recipient (Not owning a business)

Sole Proprietorship AND

Partnership

Incorporated Business

Nonprofit Organization

Governmental Entity

Business Classification Type (Check ALL that apply): (See explanation on reverse side of form) Large Small Minority Owned Women Owned Other Business Business Business Business

Does your company accept Credit Cards? Yes No

(See other side of form)

Certification: Under penalties of perjury, I certify that: (1) The number(s) shown on this form is my correct taxpayer identification number(s) (or I am waiting for a number to be issued to me), and (2) The organization entity and all other information provided is accurate, and (3) I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

You must cross out item (3) above if you have been notified by IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return.

______Authorized Signature Title

______Typed Name Phone Number Date

Certified Minority Owned Business Enterprise

If your company has been certified as a “Minority Owned Business Enterprise” by the NJ Department of Commerce and Economic Development under NJAC 17:13-1.1, please return a copy of your certification certificate with this form.

Certified Women Owned Business Enterprise

If your company has been certified as a “Women Owned Business Enterprise” by the NJ Department of Commerce and Economic Development under NJAC 17:13-1.1, please return a copy of your certification certificate with this form.

Small Business Enterprise

If your company has been registered as a “Small Business Enterprise” by the NJ Department of Commerce and Economic Development under NJAC 17:13-1.1, please return a copy of your registration certification with this form.

LAST REVISED April 9, 2003