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Pickens County Finance Department 1266 East Church Street, Suite 175 Jasper, GA 30143 Vendor Registration The following documents are required as part of the vendor registration process: Vendor List Application Vendor Conflict of Interest Certification IRS form W9 ACH Authorization (Optional) Periodic updates to this information may be requested by the Finance Department, and failure to respond to such requests may delay payment of future invoices. Pickens County Office Use Only Complete Packet Received: Date: Reviewed: Date: Entered: Date: ---PAGE BREAK--- Pickens County Finance Department 1266 East Church Street, Suite 175 Jasper, GA 30143 Vendor Conflict of Interest Certification Pickens County Government seeks to avoid business relationships which might conflict, or appear to conflict, with the best interests of the County. The purpose of this form is to identify such potential relationships with vendors. Note that responses in the affirmative to the questions below do not automatically preclude a vendor from doing business with the County. Evaluations of the responses will be made by the appropriate County personnel on a case-by-case basis. Steps to mitigate the conflict or perceived conflict may be required by the vendor and/or County personnel as appropriate. 1. Does any current or former employee of Pickens County Government hold a financial interest of greater than 5% in your organization? Yes No Unsure 2. Does any immediate family member of a current or former employee of Pickens County Government hold a financial interest of greater than 5% in your organization? Yes No Unsure 3. Has this organization or any of its principals been debarred, suspended, or otherwise excluded by a duly authorized regulatory agency or had a transaction with any such agency terminated for any reason? Yes No Unsure If your response to any of the questions above is yes or unsure, please attach a separate sheet describing the situation. Certification I do hereby certify that all responses herein are true and correct to the best of my knowledge. I understand that Pickens County Government reserves the right to modify or terminate immediately any vendor or employee relationship (as appropriate) should it be discovered that the information provided herein was known to be false at the time of this certification. Signature: Date: Printed Name and Title: SIGN ---PAGE BREAK--- ---PAGE BREAK--- ACH Authorization Form I hereby authorize Pickens County Government to initiate entries to my (our) checking/savings accounts at the financial institution listed below, and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until Pickens County Government is notified by me (us) in writing to cancel it in such time to afford Pickens County Government and The Financial Institution a reasonable opportunity to act on it. Vendor Name: Signature: Printed Name: Address: Phone: Name of Financial Institution: Name on Account: Routing Number Account Number Account Type (Circle Business Checking Business Savings Personal Checking Personal Savings Email Notification Requested: YES NO Email Address: A bank letter or voided check must be attached to this authorization. FOR OFFICIAL USE ONLY: Received: by: Attachment: Bank Letter Voided Check Entered: by: Reviewed: by: Notes: SIGN