Heartland Vendor Application

Heartland Vendor Application
Tell us About Yourself and Your Business!
Who is filling out this application?*
First and Last Name
What is your email? *
example@example.com
Formal/Legal Business Name*
This name must be the FORMAL/LEGAL name (whether it be business or personal) that you use for your taxes for this business. This name MUST MATCH the Form W-9 that you will submit and is also the name all payments will be made out to.
Other Business Name (DBA)
This is how you would like your business displayed. We will always list your legal name that you accept payments to first, but we will put any DBA name in parenthesis so that it is searchable in our catalog. For example Jane Doe who would like to be known as Tutoring by Jane will be listed as Jane Doe (Tutoring by Jane).
What is your title with the business?*
Please tell us about yourself:*

I am the authorized decision maker of a business that requests to become an onboarded vendor with Heartland.I am NOT an authorized decision maker with this business.
Website (in http://www.website.com format to be accepted)*
This will be displayed for Heartland Parents/Students. Please ensure you are providing a link with a functioning public website or social media page that is relevant to the services offered to Heartland Students. We need to be able to have public information that we can refer our families to.

Are you currently affiliated with Heartland Charter School?*

I have no affiliation with Heartland Charter School. There is no familial relationship with a Heartland family. I am not an employee.I am the family member of a currently enrolled Heartland Family. This could be a parent, grandparent, aunt, uncle, cousin, sibling, etc. of an enrolled student.I am a currently employed by Heartland Charter School.
Please list the name of any children, grandchildren, nieces, nephews, cousins, etc. that the business owner or any principle business member (president, vice president, etc.) are related to.
I understand that vendors are prohibited from providing service to a relative (e.g., child, grandchild, niece/nephew, cousin, sibling, etc.) of the vendor owner(s) or vendor’s principle organization members (President, Vice President, etc.) and that Heartland is not be responsible for paying vendor for the prohibited services.

I agreeI disagree and would like to withdraw my application

Type of Vendor?

Heartland vendors are categorized as either Product or Service. Please read below and let us know which one you are:

Product		Service
Sells products (digital or physical) via a website		Provides a service either in-person or virtually
Doesn't interact with students, including electronic interaction		Has live interaction with students

If you need help determining what type of vendor you are, please reach out to vendors@heartlandcharterschool.com and we'll help you narrow it down.

Which type of vendor are you?*

ServiceProduct

Vendor Business Information

We need to know all the ways to reach out to you. Some of this may seem repetitive, but it's helpful for others. Thank you for working your way through all of it.
Business Contact Name*
Please provide the name of the primary point of contact for all business activities.
Business Contact Email*
Please provide the email address of the primary point of contact for all business activities.
Business Contact Title*
Please provide the title of the primary point of contact for all business activities.
Business Contact Phone Number*
Please provide the best phone number for the primary point of contact.
Name of representative with legal authority to sign the Vendor Agreement*
Title of representative with legal authority to sign the Vendor Agreement*
Please provide the title of the owner, director, or other representative who will be signing the Vendor Agreement.
Email of representative with legal authority to sign the Vendor Agreement*
example@example.com
How should we send you a PO?
Please give PO instructions here:
Email address that Heartland's Ordering Department should send all Service Certificates or Purchase Orders to*
This email address is where our Ordering Department will send all certificates. This certificate is used as Heartland's promise to pay for the service on the certificate. You will also reference it when invoicing after services have been rendered.
What is your business address (as confirmed with the IRS via your submitted W-9)?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a different address where services will be provided? Choose all applicable options

Services will take place at the business address listed aboveServices will take place at a separate in-person location that I own or rent (separate office space, room for rent, etc)Services will take place in the student's home or other agreed-upon public space (library, park, or other similar location)Services are onlineDoes not apply - I am a product vendor only
Where will services take place if different from above (address including city, state, and zip).

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Vendor Services Information
General Description of the Service:*
Upon approval, this will be displayed for Heartland families to have an idea of the general services that you provide. Be as detailed as possible.
Name of best contact to be shared with Heartland families*
Please provide the name of the person that would be the best contact for families with questions about your program.
Email address to be shared with Heartland families*
Please provide the email address that would be the best contact for families with questions about your program.
EXHIBIT A - Detailed List of Services (DLS)

Approved services will be listed in the Heartland catalog and referenced in the Vendor Agreement. Please make sure they are accurate and precise. Please list each type and/or price point of service individually. Upon approval, these will be the services families can choose from for you. Be as detailed as possible in the limited space available.

To create your Detailed List of Services, please follow these directions:

1) Open THIS DOCUMENT

2) Click "Make a Copy"

3) Fill out lines the document with your services (lines 3 and below).

4) Download the document as a Microsoft Excel file (click File, hover over download, click Microsoft Excel)

5) Upload this file in the space below
EXHIBIT A - Detailed List of Services - UPLOAD FILE HERE*

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Do you have other fees that would apply to our families (registration, uniform, comp fees, etc)?*

YesNo
Please describe these fees.
Do you have any comments that you would like us to know about the services you have listed above? These will not necessarily be listed in the catalog, but could be helpful for information and approval of services.
Do you have a resume, letter or recommendation or other documents about your services that you would like to share with us? If so, please upload them here.

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Tell us about your business
Once onboarded as a PO Vendor with Heartland, would you like to receive Electronic Funds Transfers from Heartland for invoice payments?*

Yes, please sign me up for faster payments now (requires bank info)No, not now, but I can always update this by emailing ap@heartlandcharterschool.com in the future.
Click here to downlod the Electronic Funds Transfer (EFT) form. Upload your Electronic Funds Transfer (EFT) form with voided check AND a document from the bank which verifies both the account number and the routing number below. This is a requirement for all Service Vendors. You will receive a digital record of all payments.
Upload EFT & Bank Verification documents here

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Account Receivable Contact Name*
First and Last
Account Receivable Email Address*
example@example.com
Account Receivable Phone*
Please enter a valid phone number.
Please upload your Form W-9 here*

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I understand that our AP Team can only make checks payable to the name on your W9?*

Yes, I understand and my Invoice name will match my W-9 nameNo, I cannot work with this
How will you be submitting your invoices?*

Digital SurveyEmail to ap@heartlandcharterschool.com

I confirm my agreement with and the accuracy of all details previously submitted in my application.

I agreeI do not agree
Signature*

Clear
Submission Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
DLS Link
Should be Empty:

Heartland Vendor Application

Tell us About Yourself and Your Business!

Type of Vendor?

Vendor Expectations

Vendor Business Information

Vendor Services Information

Tell us about your business

Please tell us about your products