Instructions
Complete the following form with all requested information. Print, sign and date the form, and email it back to Sara Bunn at sara.bunn@state.mn.us.

Mailing Address 	
Name of City      	
Address      	
City      	
State      	
Zip Code      	
Contact Information – Please list the person who can respond if additional information is required.	
Contact Name      	
Email Address      	
Phone Number (include extension)      	
Fax      	
Tax Identification Information	
Federal ID      	
Federal ID Name      	
MN State ID Number (if available)      	
SWIFT Information 	
SWIFT Vendor ID      	
SWIFT Location ID      	

										      
Authorized Signature								Date

     
Printed Name

     
Title