VENDOR JUSTIFICATION FORM(Request for Addition, Change or Closure of a Vendor)

ORIGINATOR:Name Date

Department Phone

Authorised by (manager)

Date

REQUESTED ACTION:(please tick one) Add Change Close

Creditor’s Reference Number (if existing)

TYPE OF VENDOR:

Critical item supplier Yes No

SUPPLIER OF:(tick those that apply)

Goods On-site Services Off-site Services

Other Specify

Estimated Annual Business? $ Estimated Orders per Month?

Why Add or Delete?

Alternative vendors considered Yes No

Delete vendor(s)

VENDOR DETAILS:Company Name

A.B.N

Name of Bank Address of Bank

Vendor Bank Details – BSB Account No

Vendor Bank Account Name

Postal Address

Country/State Postcode

Pick-up Address

Country/State Postcode

Contact Name Facsimile

Phone Mobile

E-mail Website

After Houses Contact Details Name

Phone Mobile

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VEN

DO

R A

SSES

SMEN

TPU

RC

HA

SIN

G D

EPA

RTM

ENT

USE

ON

LY

Electronic Funds Transfer Capable? Yes No

City of Fremantle’s Electronic Funds Transfer Authority completed and attached? Yes No

Electronic Commerce Capable? Yes No

Capability (detail)

INSURANCE

Insurances Required ? Yes No TYPE(tick those that apply) Public Liability Professional Indemnity

Workers Comp. Motor Vehicle

Certificates Sighted? Yes No

Copies Received Forwarded to Risk Management Date

PRE-QUALIFICATION

Required Not Required

Request Sent (date) Returned (date)

Comment

Recommendation

APPLICATION APPROVAL

Approved? Yes No (If ’yes’ update Creditors)

VENDOR TYPE (circle one) V = Vendor O = Obsolete PF = Preferred Vendor

What is the service class? (eg Cleaning, Consultancy, Festival)

If ‘yes Contractor database updated? Yes No

If ‘no’ Requestor Advised? Yes Date

Approved - Purchasing Team Leader Date

ACCOUNTS USE ONLY

Record updated in Creditors on Date

New Creditor # Signed

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