Supplier Registration

If you have any questions while completing this form you can contact us at purchasing@ceridian.com.

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Supplier Registration Form

Today's Date 11/20/2009
Company Services / Products *
Commodities or Services your company provides *
Legal Name of Company/Individual *
Your Email Address *
Telephone *
Sic Code *
NAICS
Tax ID Number/SS# Individual *
D&B Number *

Type of Business

Proprietorship Partnership Corporation Government Military

Name of Owner
Please use this link to access the IRS website and complete a W-9 for 1099 purposes
http://www.irs.gov/pub/irs-pdf/fw9.pdf. When completed fax form to 727-395-8980.

List Partners

State incorporated and if publicly traded provide symbol

Number of Years/Business *
Number Employees

Home Office Information

Address *
City *
County *
State *
Zip (must enter your 9-digit zip code)*

Remittance Information

Address
City
County
State
Zip (must enter your 9-digit zip code)
Routing Number*
(Field is required to be filled in to receive payment.)
Bank Account Number*
(Field is required to be filled in to receive payment. Ceridian will automatically ACH payment to account.)

Manufacturing Information

Website Address

Single Point of Contact

Name *
Title *
Telephone *
Email Address*

Your Company Information

Products and/or Services your company provides:*
Have you provided products or services to Ceridian or affiliates previously? * Yes No
If yes, give brief description and location.
(Please keep comments to one paragraph and don't use line returns.)
Does your firm maintain all necessary licenses to conduct business? * Yes No
Do you maintain the necessary insurance on your personnel should they be required to enter Ceridian premises? * Yes No
Payment Terms - NET 30? * Yes No

Details/additional comments:

Equal Employment Opportunity Compliance Certification

A. Has or will your company file the required employer information report EEO-1 (standard form 100) with the secretary of labor's joint reporting committee for the last calendar year by the required filing date? Yes No

Please check the following appropriate reason for not filing
1. Employ less than 100 people
2. Have not received any of the following:
a) Prime contract of first-tier sub-contracts for $50,000 or more
b) Any tier construction contract for $50,000 or more
3. Have specific exemption from secretary of labor as provided in section 204 of executive order 11246 as amended by E.O. 11375

B. Do you have at each of your facilities a written affirmative action compliance program as called for in 60-2.40 and 60-2 (revised order 4) of title 41 of the code of federal regulations? Yes No

Is it current Yes No

Within 20 days after receipt of any order of $50,000 or more from Ceridian, the contractor, if it has fifty (50) or more emaployees and is not otherwise exempt by the law or regulations, agrees to develop an affirmative action compliance program for each of its facilities.

C. Seller has has not held contracts or sub-contracts subject to the equal opportunity clause of executive order 11246, as amended by E.O. 11375

Conflict of Interest Statement

Do you have any family, business, or financial relationship with any employees, subcontractors, partners or competitors of Ceridian? * Yes No

Details/additional comments:

Ceridian Supplier Diversity Sign-up

If your company falls into one of the following business classifications it is necessary to continue the registration process by selecting your classification information. This will be used by Ceridian solely for monitoring supplier classifications, developing and improving our supplier diversity programs, and filing governmental reports as may be required by applicable regulations.

If your company falls into one of the following business classifications it is necessary to continue the registration process by selecting your classification information. This will be used by Ceridian solely for monitoring supplier classifications, developing and improving our supplier diversity programs, and filing governmental reports as may be required by applicable regulations.

If you require assistance in understanding these categories, you are encouraged to visit the following sites or agencies for additional information:

Small Business Administration (http://www.sba.gov/)
National Minority Supplier Development Council (http://www.nmsdcus.org/)
Women's Business Enterprise National Council (http://www.wbenc.org/)

NOTE: If you are a large business and are not classified in any of the categories below there is no further response necessary. Scroll to the bottom of this form and submit.

Are you certified (by the US Small Business Administration or another certifying agency) in one of the business classifications described below? Yes No

Please provide the following information
Certification Number (if applicable)
State Certification was Issued:
Expiration Date (MM/DD/YYYY)
Please continue to register by selecting a business classification from the list below.

Please continue to register by selecting a BUSINESS CLASSIFICATION from the list below.

Supplier Registration

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