BROUSS Elevators — Vendor Setup

1 Business Information

Legal Business Name (or Full Legal Name if individual) *

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DBA / Trade Name (if different)

Tax Classification *

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Tax ID Type *

EIN SSN

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Tax ID Number *

Please enter a valid Tax ID

Street Address *

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City *

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State *

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ZIP *

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Phone *

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Email *

Please enter a valid email

Main Contact Name *

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Title / Position

2 Vendor Type & Services

Vendor Type *

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Brief description of services/products provided

3 Payment Information

Payment Preference *

Check ACH / Direct Deposit

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Bank Name *

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Routing Number *

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Account Number *

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Account Type *

Checking Savings

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4 Documents Upload

Upload Documents

Click or tap to upload (PDF or image)

5 W-9 Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding

3. I am a U.S. citizen or other U.S. person

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct

Full Name (typed signature) *

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Date

I certify the information above is correct *

You must certify to submit