As a result of legislation enacted by congress, effective after December 31, 1983, a $50.00 penalty may be imposed for failure to file Form 1099 (Information Return) or for failure to provide taxpayer identification numbers.  Vendors required to provide an identification number, who do not comply, will be subject to 20% withholding of all vendor payments until an identification number is filed with us.  Therefore, we are asking that you supply us with the following information to insure that our records reflect correct information in the event that we are required to file a Form 1099 for you.

Employer Identification Number ______________________________

Or Social Security Number ______________________________

Check the appropriate description of your business:

_____ Individual Proprietorship

_____ Partnership

_____ Medical Corporation

_____ Corporation

Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number.


Signature _____________________________                                           


Title ____________________________________    Date  __________________________


Name and Address: __________________________________________

                                   __________________________________________

                                   __________________________________________

                                   __________________________________________