VENDOR REGISTRATION FORM INSTRUCTIONS

Size: px

Start display at page:

Download "VENDOR REGISTRATION FORM INSTRUCTIONS"

Lionel Pope
7 years ago
Views:

1 VENDOR REGISTRATION FORM INSTRUCTIONS This form can be completed online and can be sent to the Purchasing Department via to or faxed to (352) A vendor application number will be assigned to the application. The following information must be completed in its entirety for input into the College s Vendor Mailing List database (Incomplete applications will not be processed): Block 1. Company Information Please provide all of the pertinent company information requested in the spaces below. The Federal Employee Identification Number (FEIN) or applicants Social Security Number must be included in the space provided in order to process the request. The college will not retain any information about your firm without the above. Block 2. Type of Organization Please check applicable box that indicates your organizations structure. Block 3. Disadvantaged/Minority Status While the college does not establish specific goals for minority set asides, it does strongly encourage participation by minority, and non minority qualified firms. If your firm is a minority firm or if you have obtained certification by the State of Florida, Office of Supplier Diversity, (OSD) (CMBE), please indicate the appropriate minority code by checking the appropriate box and providing the certification number and effective dates of certification. Block 4. Construction Contracts Please provide bonding limits and bonding company(s) utilized and indicate large projects by location and value completed in the past two (2) years in the spaces provided. Certification Provide name and title of authorized company representative. By signing the application you are certifying that the information contained herein is true and correct to the best of your knowledge, and complies with F.S. Chapter 112, Conflict of Interest. Applications not signed or dated will be returned and will not be entered into the current database. The Lake Sumter State College vendor database is updated periodically. Vendors will be purged from the College Vendor file keeping information current or after three (3) unresponsive competitive solicitations. Applications will be held on file for a period of three (3) years.

2 Vendor Registration Form Purchasing Department Williams - Johnson Building 9501 US Highway 441 Leesburg, FL Phone: (352) Fax: (352) Date: Office Use: 1. COMPANY INFORMATION Federal Tax ID # or Ownership SSN: Company Name: d/b/a Address: City: ST: Zip: - Telephone: ( ) - Ext: Fax: ( ) - Web Site: Person(s) authorized to sign bids and contracts: Title(s): Contact Person Name: Title: Telephone: ( ) - Ext: Fax: ( ) - Remittance Address: City: ST: Zip: - 2. TYPE OF ORGANIZATION Individual (1) Partnership (2) Non-Profit (3) Corporation (4) Incorporated under the laws of the State of: If publicly traded please provide SEC Code: 3. DISADVANTAGED / MINORITY STATUS If your firm is considered a disadvantaged or minority firm, please select the appropriate status from the drop down menu below. If you are a certified or disadvantaged minority business enterprise (CMBE) by the Florida Office of Supplier Diversity (OSD), please provide the certification number and effective dates in the spaces provided below if applicable: Check here if not applicable: Not applicable OSD Minority Codes (Certified MBE) H (African-American) I (Hispanic) J (Asian-American) K (Native-American) M (American Woman) W Certified Service-Disabled Veteran OSD Certified? Yes No OSD Certification No. Effective Date to Other Minority Status(MBE) (African-American) (Hispanic) (Asian-American) (Native-American) (American Woman) (Disabled) 4. CONSTRUCTION CONTRACTS Bonding Limits $ Bonding Company: List largest projects completed in the last two years to which you could provide references: Project Name Contact Person Location Contract Value Phone Number NOTE: If requested, contractor should be capable of providing certificates of insurance, namely Workers Compensation and/or General Commercial Liability. 2

3 COMMODITY CODES: Please check those categories on the commodity code list provided below to indicate which goods or services your company may provide. Applications returned without completed commodity code entries will not be entered into the vendor database. If the product or service you provide does not appear in the listing, please add the information in the space marked other. Multiple categories may be checked. CERTIFICATION I certify that the information supplied herein (including all attachments) is correct to the best of my knowledge. I further certify that in doing business with the State of Florida, my firm is in compliance with Chapter 112, Florida Statues, conflicts of interest, and that I have disclosed the name of any state employee who owns directly or indirectly, an interest of five percent or more in the above firm or any of its branches. **Applications not signed or dated will not be entered on the vendor database. ** Print Name Title Signature of authorized representative Date Incomplete applications will not be processed or returned. 3

4 Commodity/Service Code Lake Sumter State College Purchasing Department Commodity Code Listing Vendor Registration Form Commodity /Service Description Air Conditioning: Equipment/Accessories/Services Check Applicable Box(es) Arts and Crafts, Educational Audio-Visual, Educational Equipment and Supplies Automobile and Trucks Capitalized Equipment greater than $ Automobile and Trucks Non Capitalized less than $ Automobile & Truck Accessories Automobile & Truck Maintenance & Repair Services Automobile & Truck Replacement Parts Barber and Beauty Shop (Cosmetology) Nails Equipment and Supplies Chemicals; commercial not else classified Clothing, Apparel, Uniform Sales, Rental, Cleaning Services Computer: Data Processing Equipment, Systems, Supplies Computer: Software Computer Services Construction: Building Supplies and Materials Construction, Buildings & Structures-Fabricated Concrete Products, Supplies and Services(Including Asphalt/Paving) Fencing, Materials, Supplies, Installation Services Copying, Duplicating Supplies, Equipment and Services Culinary; Utensils, Equipment, Glassware, Supplies/Services Furniture; Office Furniture; Educational Furniture; Moving, Set Up, Removal Services Dental; Equipment and Supplies Drugs, Educational, Miscellaneous Electrical Equipment and Supplies (not cable and wires) Electrical Cable and Wires Elevators, Sales and Services Engineering, Surveying, Blueprinting, Mapping Equipment, Services and Supplies(including A/E Services) Fertilizers and Soil Conditioners, Horticulture Supplies, Materials and equipment Financing Services Fire Protection Supplies and Services First aid and Safety Products, Supplies and Services Flags, Flagpoles, Banners & Access Floor Coverings, Supplies and Services Floor Maintenance Machines Fuel, Lubricants, and Oils and Fuel Oil Services Food, Service, Equipment and Machinery Food, Catering Services, Supplies and Equipment 4

5 Commodity/Service Code Commodity /Service Description Heating Units, Ventilating Equipment and Services Check Applicable Box(es) Heavy Equipment Sales, Repair and Rental Hardware, Hand Tools, etc Insurance Services Janitorial Supplies, Service and Equipment Laboratory Equipment, Educational Lawn Equipment Lease Rental Tangible Property Lease Rental Real Estate Library Machines and Supplies, Equipment Lumber Material Handling /Equipment Musical Instruments and Supplies and Repair Services Office Supplies, Miscellaneous Paint Supplies, Equipment and Accessories Park, Playground Recreational Equipment Plumbing Equipment, fixtures and supplies Printing Services Publications/ Periodicals/Subscriptions Consulting Services, other Recycling equipment, services Refrigeration Equipment, Sales, Services Shredding Equipment Sales, Services Safety Equipment, Protective Clothing Seeds and Sod, Supplies and Equipment Sporting and Athletic Goods Services Motor Coach /Transportation Services Telecommunications, Sales, Supplies and Services (including Cellular and Mobile Equipment) Television equipment and Accessories Venetian Blinds, Shades, Awnings Theatrical equipment and Supplies, Services Veterinary Equipment and Supplies including Equine Supplies and Services Services; Educational, Speakers, Presentations Services; Legal Landscaping Services Construction/General Contractor Building and Structures Batteries/All Types Undefined/Not Specified Furniture: Recreational/Sports/Outdoors Decorating: Furniture Non Office 5

Please return or fax all completed forms to the address listed below. Please retain a copy for your records.

Please return or fax all completed forms to the address listed below. Please retain a copy for your records. Please be advised that in order to obtain a Dallas Independent School District Vendor Number the following procedures must be completed: PLEASE READ CAREFULLY 1. Please complete, sign and date all pages