Florida Department of Agriculture and Consumer Services Division of Food, Nutrition and Wellness FOOD SERVICE VENDOR REGISTRATION / RENEWAL FORM
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1 Florida Department of Agriculture and Consumer Services Division of Food, Nutrition and Wellness ADAM H. PUTNAM COMMISSIONER FOOD SERVICE VENDOR REGISTRATION / RENEWAL FORM 7 CFR (a)(5) Please select one: NEW Food Service Vendor Applicant, or Food Service Vendor Renewal VIN #: VENDOR INFORMATION Company Name: Doing Business As, if applicable: Mailing Address Line 1: Mailing Address Line 2: City, State, Zip Code: County: Regional Address Line 1: Regional Address Line 2: City, State, Zip: County: Website: List all names/aliases you have used in the past 24 months, if applicable: Page 1 of 6
2 CONTACT(S) FOR PROCUREMENT NOTICES This information will be listed publicly on the FDACS Food Service Vendor List. Please provide the information below for one or two representatives to receive procurement notices, solicitations from sponsors, s from FDACS and annual vendor training opportunities. Representative 1 Contact Name: Title: Telephone Number: Fax Number: Address: Representative 2 (Optional) Contact Name: Title: Telephone Number: Fax Number: Address: AUTHORIZED SIGNATORIES Please provide a list of individuals that are authorized to enter into contractual agreements. Name (Last, First) Title Page 2 of 6
3 CORPORATE PROFILE Yes No N/A [C1] [C2] [C3] Is your company incorporated? If yes, the date of incorporation is. Is your company certified as a Minority-Owned, Woman- Owned, or Veteran-Owned Enterprise? If yes, please submit current certification. Has your company been terminated for cause in the past 36 months? If yes, please attach written explanation. Primary Business Function Please mark the one box that best describes your company. Caterer Restaurant Food Service Management Company Other: Previous Experience Mark the box next to each United States Department of Agriculture (USDA) program that your company is currently or has provided meals to in the past 36 months. (NSLP) National School Lunch Program (SFSP) Summer Food Service Program (SBP) School Breakfast Program (FFVP) Fresh Fruit and Vegetable Program (SMP) Special Milk Program (ASSP) Afterschool Snack Program Primary Program(s) Mark the USDA program that your company has an interest in participating. (NSLP) National School Lunch Program (SFSP) Summer Food Service Program (SBP) School Breakfast Program (FFVP) Fresh Fruit and Vegetable Program (SMP) Special Milk Program (ASSP) Afterschool Snack Program Page 3 of 6
4 NUTRITION INFORMATION Minimum Conditions List any conditions that must be met in order for your company to consider submitting a proposal/bid to a sponsor (i.e. minimum number of meals/day, minimum number of schools, cold meals only, etc.). Specialty Menu Mark the box next to each specialty or diet menu that your company can provide. Please mark all that apply. V Vegetarian H Halal VG Vegan L Latin F Gluten-Free N All Natural DF Dairy-Free R Renal PF Peanut-Free K Kosher PKF Pork-Free P Puree CF Casein-Free ORG Organic SF Salt-Free SS Shelf-Stable ALG Special Allergy DIAB Diabetic LS Low-Sodium Other Page 4 of 6
5 SERVICE AREA(S) Mark the box next to each Florida county or counties that your company is able and willing to contract for food services. Alachua Franklin Lee Pinellas Baker Gadsden Leon Polk Bay Gilchrist Levy Putnam Bradford Glades Liberty Santa Rosa Brevard Gulf Madison Sarasota Broward Hamilton Manatee Seminole Calhoun Hardee Marion St. Johns Charlotte Hendry Martin St. Lucie Citrus Hernando Miami-Dade Sumter Clay Highlands Monroe Suwannee Collier Hillsborough Nassau Taylor Columbia Holmes Okaloosa Union DeSoto Indian River Okeechobee Volusia Dixie Jackson Orange Wakulla Duval Jefferson Osceola Walton Escambia Lafayette Palm Beach Washington Flagler Lake Pasco Page 5 of 6
6 REQUIRED DOCUMENTATION Please submit the following documents: A copy of the two (2) most recent health inspections for your facility. o (Only applicable if meals are prepared in a facility not controlled by a sponsor, i.e., catering kitchen, restaurant, etc.) A food manager certification for each facility where program meals are prepared. o (Only applicable if meals are prepared in a facility controlled by a sponsor, i.e., school, summer camp, church, etc.) Business license Proof of insurance Certificate Regarding Lobbying Disclosure of Lobbying Activities Minority-MBE, Woman-WBE, or Veteran-VBE Owned Business Certification (if applicable) Written explanation for termination (if applicable) CERTIFICATION I certify that the information submitted on this application for registration is true and correct and that the company is aware that misrepresentation may result in prosecution under applicable state and federal statutes. SIGNATURE OF AUTHORIZED OFFICIAL PRINT NAME Date Date Page 6 of 6
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