CREATE W9 and Vendor Form Upload - Colorado Rural Health Center

Applicant Organization Name*
W-9 Upload
Attach your organization's signed W-9 below. If part of a larger entity, submit a W-9 for the parent taxable entity where the organization name is reported.
Download a blank W-9.
W-9 Attachment*
Max. file size: 50 MB.
Vendor Form
Complete the following Vendor Form using the applicant agency's information.
Vendor Name*
Other Entity Names Under Same Tax ID Number
Please email a separate document to accounting@coruralhealth.org listing the entity names in addition to their mailing and physical addresses if this applies to you.
Check should be made payable to*
Mailing Address (WHERE CHECKS SHOULD BE MAILED TO)*
Street Address Address Line 2 City State ZIP Code
Physical Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Vendor Contact Name and Title*
Vendor Contact Email*
Federal Employer Identification Number (FEIN)*
Affiliated RETAC
Find the RETAC your entity's county is affiliated with.
RETAC Affiliated With*
Agency Type
What is your entity agency type?*
CREATE Applicant Acknowledgement
By checking the box and typing your name below, the applicant confirms they have read and understand the grant guidelines and the range of scores possible for each section of the narrative.
View CREATE Grant Guidelines
CREATE Grant Guidelines*
- I have read and understand the grant guidelines.
Authorized Grant Contact Name*

W-9 Upload