Vendor Name
Trade Name
BUSINESS POINT OF CONTACT NAME
BUSINESS POINT OF CONTACT EMAIL
BUSINESS POINT OF CONTACT TELEPHONE
VENDOR ADDRESS
VENDOR COUNTRY OF RESIDENCE
TAX ID NUMBER
DOMESTIC OR INTERNATIONAL VENDOR Domestic (US)International (Non-US)
ORGANIZATION TYPE (if Domestic please select one) Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/EstateNonprofit
DIVERSE BUSINESS CERTIFICATIONS (please select if applicable) Not ApplicableWomen Business Enterprise (WBE)Minority Business Enterprise (MBE)Veteran Business Enterprise (VBE)Business Enterprise owned by People with Disabilities (BEPD)Small Business Enterprise (SBE)
VENDOR REGISTRATION NUMBER (S) (please list all states and license numbers available)
HAVE YOU PREVIOUSLY DONE BUSINESS WITH POINTSBET UNDER A DIFFERENT COMPANY NAME YesNo
IF YES, UNDER WHICH NAME
