EmailMeForm
2020-2021 Community Partner App:
Thank you for your interest in becoming a Community Partner for Pacific Charter Institute and its family of schools: Heritage Peak Charter School, Rio Valley Charter School, Valley View Charter Prep, and Sutter Peak Charter Academy. Please complete all sections of this request form for consideration to become a PCI Community Partner.
NOTE: Please proofread your responses/answers as they will not be automatically corrected.
1
Community Partner Information
2
Service Information
3
Additional Business Information
4
Liability Insurance
5
PCI Invoice Requirements & Active Vendor Protocols
6
Agreement & Acknowledgement
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1
Community Partner Information
2
Service Information
3
Additional Business Information
4
Liability Insurance
5
PCI Invoice Requirements & Active Vendor Protocols
6
Agreement & Acknowledgement
Business Information
Business Name
*
The Business Name will be used as the listing on the public listing of the Community Partner List upon application approval.
Business Address
*
City
*
This will be listed on the public listing of the Community Partner List upon application approval.
State
*
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
This will be listed on the public listing of the Community Partner List upon application approval.
Zip Code
*
County
*
COUNTY the business is located. This will be listed on the Community Partner List upon application approval.
Phone Number
*
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####
This will be listed on the Community Partner List upon application approval.
Fax
###
-
###
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####
This will be listed on the Community Partner List upon application approval.
Business Email
*
This will be listed on the Community Partner List upon application approval.
Website
This will be listed on the Community Partner List upon application approval.
Length of Time in Business
*
Owner/Manager Information
Complete this section if different from Business Information.
Name of Owner/Manager
Title
Phone Number
###
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Contact Email
Payment Information
W-9 Attachment
*
Click on Browse to locate and attach a copy of your W-9. In order to issue payment on future invoice submissions should this application be approved, the W-9 must be filled out in its entirety. Failure to attach a completed W-9 may result in a delay to the application process. Acceptable file formats include .jpg, .jpeg, .pdf, and .png.
Pay to the Order of
*
Pay to the order of must match the information provided on the W-9.
Remittance Address
Address of where checks and correspondence will be mailed. Complete if different from Business Address.
City
State
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
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