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PITTSBURGH PUBLIC SCHOOLS M/WE Program Vendor Application Affidavit Please complete this form and return it to: Pittsburgh Public Schools M/WE Program Coordinator 341 S. Belle field Avenue Pittsburgh,

DATA RECIPIENT STATUS: IV. REQUEST FOR DATA: A. COMPANY AND PERSON: Name of Company (if different from above) Taxpayer ID 000 Amount of Business 000 000 Year of Purchase of System 000 000 B. BUSINESS: (if different from above) Business name of business (if different from above) Taxpayer ID 000 Company name is different from above Business Address (if different from above) City, State, Zip City and State of Location (if different from above) Zip Phone (if different from above) C. BUSINESS NAME: Business Name is different from above Company is different from above Phone is different from above IV. REQUEST FOR PERSONAL INFORMATION: Name of Person who submitted request for data (if different from above) Taxpayer ID 000 Name of Person who wants to contact you 000 Phones (if different from above) EEO/ADA/SSA Certificate IV. DATA RECIPIENT STATUS: Data Recipient has completed all paperwork on this request I. INFORMATION REQUESTED: Name of person requesting for data (if different from above) 000 Phone (if different from above) II. REQUEST EXPLICIT STATUS: I have the intent to use or disclose the data in your requested form (if different from above) Taxpayer ID 000 III. DATA NOTIFICATION: I request a copy of the information requested (if different from above) IV. DATA RECIPIENT STATUS: Data Recipient has not completed any paperwork I. INFORMATION REQUESTED: Name of person who submitted information request (if different from above) Taxpayer ID 000 IV. DATA RECIPIENT STATUS: Data Recipient has not completed any paperwork I. INFORMATION REQUESTED: Name of person who requested for data (if different from above) Taxpayer ID 000 IV.

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