Multiple Scheduling Coordinator Form Maryland and District of Columbia

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1 Multiple Form Maryland and District of Columbia In order to register a multiple scheduling coordinator, you must already be a registered supplier in Pepco. Please send the completed executed form to: Pepco Supplier Relations 701 Ninth St N.W., Rm Washington, DC Company Information Legal Business Street Address: City, State, Zip Code: Trading as name if different: Federal ID NO: Licensing Data MD License Number: Date of License: DC License Number: Date of License: and DC Page 1 of 8

2 Banking Information (W9 required) Bank Address: Contact at the Bank: Name on Account: ABA Routing: Account Number: Supplier s Contact Information (Printed on Pepco s Consolidated Bill) Telephone Number: Address: Mailing Address: Supplier s Short Name (10 characters used for labels): Multiple (If registering more than 1 MSC, please fill out page 5) Is there a separate entity that has been appointed as the scheduling coordinator? If yes, provide the Page 2 of 8

3 Certification Applicant hereby warrants and represents that all statements and representations made herein, and on any supporting documents, are true and correct. The undersigned hereby certifies that he/she is authorized to sign this application on behalf of applicant, and that applicant agrees to be bound by all statements and representatives contained in this Supplier Registration form. Authorized officials of the Applicant warrants that the Applicant agrees to be bound by this representation: Submitted By: Applicant s Company Signature of Authorized Official: Name of Authorized Official: Title of Authorized Official: Date Signed: Page 3 of 8

4 Contact Information (Update all appropriate contacts) Main Contact Title: Address: EDI Contact Title: Address: Invoicing & Accounting Contact Title: Address Billing Contact: Title: Address: Page 4 of 8

5 Multiple s and DC and DC Page 5 of 8

6 and DC and DC Page 6 of 8

7 and DC and DC Page 7 of 8

8 and DC and DC Page 8 of 8

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