INTERNATIONAL SUPPLIER CERTIFICATION

FOR PAYMENT TO OCCUR, Supplier must complete this supplier certification, and return it to the CH2M HILL requestor listed below.
NOTE: THIS FORM IS TO BE USED ONLY FOR SUPPLIERS WHO ARE INTERNATIONALLY BASED AND WILL ONLY PERFORM WORK INTERNATIONALLY. DO NOT USE
IF SUPPLIER WILL BE PERFORMING WORK IN THE UNITED STATES OR FOR A SUPPLIER WHO IS BASED IN THE UNITED STATES AND WILL PERFORM WORK
INTERNATIONALLY.
Legal Name: _________________________________________________________________________________________________
(If individual, enter last name first)
Trade Name (Doing Business As): _________________________________________________________________________________________________
(If additional purchasing or payment sites are applicable, please attach additional site information.)
Mail PURCHASE ORDERS to: Mail PAYMENTS (leave blank if address is the same) to:
Attn: ________________________ Title: _________________ Attn: ________________________ Title: _________________
Street ____________________________________________________ Street ____________________________________________________
Address: Address:
City: ____________________________________________________ City: ____________________________________________________
Country: ________________________ Zip: _________________ Country: ________________________ Zip: _________________
Telephone: ____________________________________________________ Telephone: ____________________________________________________
Fax: ____________________________________________________ Fax: ____________________________________________________
Email: ____________________________________________________ Email: ____________________________________________________
VAT TAX ____________________________________________________
ID#:
WIRE TRANSFER INFORMATION
Account Name ______________________________________________________________________________________________________________
Bank ______________________________________________________________________________________________________________
Bank Address ______________________________________________________________________________________________________________
Account Number ______________________________________________________________________________________________________________
Sort Code ______________________________________________________________________________________________________________
Swift ______________________________________________________________________________________________________________
IBAN ______________________________________________________________________________________________________________
SUPPLIER CERTIFICATION: By signing below, Supplier certifies, that the above representations are accurate, current, and complete. The Supplier further certifies that it will
notify CH2M HILL of any changes to these representations.
___________________________________ ___________________________________ _______________
Supplier Authorized Signature Name (printed) Title Date Signed
FOR CH2M HILL INTERNAL USE ONLY
CH2M HILL Requestor Information ________________________________ Office Code ________ Operating Unit/Company No. ____________

INTERNATIONAL SUPPLIER CERT. 03-2005