NEW

SUPPLIER REQUEST FORM

Please fill out & save as MS word document and
email to purchasing@FireEye.com

*FireEye Requestor*: Barbeque Nation Hospitality Ltd

*SUPPLIER INFORMATION
Business Name: Barbeque Nation Hospitality Years in Business: 11
Ltd
DBA/Alias/Alternate Name: Atmosfire
Business Address: Rytham Square, 4th Floor, Site No. 94, 14th Cross, Neeladri
Nagar, Electronics city
City/State: Bangalore Zip Code: 560100
Country: India
Primary Contact: Arun V P Contact Email:
arun.v@getatmosfire.com
Contact Phone: 9880485858 Contact Position: Business Manager

*REMIT TO: (Where payment will be sent, if different from above)

Remit-To Address: Rytham Square, 4th Floor, Site No. 94, 14th Cross, Neeladri
Nagar, Electronics city
City/State: Bangalore Zip Code: 560100
A/R Contact: Shekar A/R Email: shekar.p@getatmosfire.com
Payment Terms: Net 30 If other, specify: Click here to enter
text.
Payment Method: If other, specify: Click here to enter
Wire Transfer text.

Invoice Currency: Indian Rupee (INR)

*BUSINESS DETAILS
Organization Type: If other, specify: Public Limited
Other- Specify

Business Description: Food & Beverage service

Product/Service Classification Type: P/S Code: Click here to enter
Choose an item. text.

*ADDITIONAL DETAILS FOR US COMPANIES

TAX Id- type: TAX Id #: Click here to enter text.
Choose an item.

Are you exempt from backup withholding? Yes No

*Are you a 1099-MISC recipient? Yes No
*Federal Income Tax Law requires a Form 1099 Information Return with a valid Taxpayer Identification
Number to be filed for certain payments over $600.00 made in the course of conducting a trade or business.
Furthermore, these payments may be subject to Backup Federal Income Tax Withholding for all payees who
have not submitted a valid Federal Tax Identification Number at the time of payment.
*California Franchise Tax Board requires 7% Withholding tax form distributions of California source income
provided to Domestic Non-Resident contractors
Please check off appropriate box that permits to Non-Resident Contractor CA withholding:
Yes, withhold CA Tax from my California source income No, Do not withhold taxes (Please provide a copy of
approved Waiver form
Are you a Minority or Women-owned Business?: Yes No *If yes
select below
Classification: Minority Type:
Choose an item. Choose an item.

Certified By: Click here to enter text. Expiration Date: Click here to enter
text.
*ADDITIONAL DETAILS FOR NON-US COMPANIES
TAX Id- type: If other, specify: Click TAX Id #: 29470795881
VAT here to enter text.

Non-US Entity: Are you providing services to FireEye US & are you
operating in the US? Yes No
If yes, please provide IRS Form W-8BEN, W-8EXP, or W-8ECI (available at IRS.gov)
If no, please provide other form of identification, such as a business license or tax id
certificate

PAYMENT/FINANCIAL INSTITUTION INFORMATION

Bank Name: Axis Bank Ltd
Intermediary Bank (if applicable): Click here to enter text.
Bank Address: 100 Feet Road, Indiranagar
City/State: Bangalore Zip Code: 560038
Bank Account Number: 912020047889947
IBAN Account Number (For EU): Click here to enter text.
Bank Transit (ABA/Routing/CHIPS#-For US): Click here to enter text.
Bank Account Type: Checking Savings
Other
For International Use:
Bank Code Type: Enter Bank Code: UTIB0000114

CERTIFICATION AND REQUIRED

SIGNATURE
1. I hereby certify under penalty of perjury that the 3.
information provided is true and correct. The number
shown on this form is my correct Taxpayer
Identification Number, and
2. I am not subject to backup withholding either because I
have not been notified by the Internal Revenue Service
 (IRS) that I am not subject to backup withholding as a
result of a failure to report all interest or dividends, or
the IRS has notified me that I am not subject to backup
withholding.
Electronic Signature: (Double click to sign)

FIREEYE INTERNAL
W9 Received: Yes No Background check: Yes No MSA
Signed: Yes No
Insurance: Yes No NDA: Yes No Security Assessment Yes
No N/A

For your knowledge: FireEye Inc. SVB Wire Requirements

UK Australia APAC India Mexico/Lati
n America
Account X X X X X
IBAN X X
Sort code X X
Swift Code X X
BSB X
Phone # X X
IFSC X
Tax ID X X
CLABE X