Headquarters
AEVENIA, Inc.
3030 24th Avenue South
Moorhead, MN 56560

Phone: 218-284-9500
FAX: 218-287-1963

Vendor Application

To be completed by VENDOR ONLY

Please fill out and print the form below, and either fax to: 218-284-9555, or mail it to:
AEVENIA, Inc.
3030 24th Avenue South
Moorhead, MN 56560

Or, download the pdf form, complete and return it by fax or mail.

Application Type  New Vendor  Reactivate Vendor  Address Change
Vendor Number
(Existing Vendors)
Vendor Type  Corporation  Government Agency  Individual/Sole Propietor
 Non-Profit  Partnership
Name
 (As it appears on checks; No Abbreviations.)
Doing Business As
 (If different than name on check.)
Business Classification  Small Business  Disadvantaged
 Woman Owned  Veteran Owned
(Check all that apply) *Please attach supporting documentation
Business Address
  City State Zip
  Accounts Receivable Contact
Phone Number
Fax Number
E-Mail Address
Send Payments To
(If different from Business Address)
  City State Zip
  Phone Number
Fax Number
Owner of the Tax Payer Identification Number (TIN or SSN)
  Name
Social Security Number
Federal TIN
If you would like to enroll in EFT please complete the following fields
  Financial Institution
Routing Number
Account Number
Enter Your Name
Enter the Date
Under penalties of perjury, I certify that the number shown on this form is my correct
taxpayer identification number or I am waiting for a number to be issued to me.

Please fill out completely. An incomplete form will create a delay in our payment(s) to you and your payment(s) could be subject to the IRS required back-up withholding.