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Supplier Registration Form

I. Business Information
*Company Name
*Contact Person: 
 Title:
*Street Address: 
Suite No:
*City:
 
 *State:
*Zip:
*Telephone
Fax:
Email
Website Address:
*Federal Tax ID/
Ownership SSN
Organization Type:  
Under the Laws of: 
If Outside of USA, select Country: 
Payment Terms:
Do you accept
payment by Visa credit card?		Yes No
*The Federal Tax ID No. or the ownership SSN must be included or your company will not be established in the Broward College vendor database.
 
II. Accounting Information
*Payment Address  
Suite No:
*City:
*State: 
*Zip:
 If Outside of USA, enter Country: 
*Contact
Title:
*Telephone:  Fax:
Email
 
III. Purchase Order Information (complete this section only if information is different from section 1)
Payment Address:
Suite:
City:
State
Zip:
If Outside of USA, enter Country: 
Attention:
Title
Telephone
Fax
E-Mail
 
IV. Material Return Information (complete this section only if information is different from section 1)
Payment Address:
Suite:
City:
State
Zip:
If Outside of USA,
select Country: 
 
Attention:
Title
Telephone
Fax
E-Mail
 
V. Sales Information
*Contact Person:
Title:
*Telephone:
Fax
E-Mail
 
V. Sales Information
If your company qualifies as a minority/woman business enterprise, please complete this section of the vendor application.
 
1. Is your business a certified Minority-owned or Woman-owned enterprise?      Yes No
Broward College accepts certifications issued by:
 
If you are not certified and with to become certified, you may contact the Minority Purchasing Coordinator at (954) 201-7455.
 
 2. Please select the classification(s) which are applicable to your business (certified & non-certified vendors)
  ASN - Asian American    HSW - Hispanic Woman   
  ASW - Asian American Woman     HIS - Hispanic   
  NAA - Native American     NAW - Native American Woman  
  BLK - Black     BLW - Black Woman   
  WOM - Caucasion American Woman   
 
VII. Statement of 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 STATUTES, 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.


_______________________________
SIGNATURE OF PERSON AUTHORIZED TO SIGN THE
APPLICATION		          ________________________________________
         NAME & TITLE OF PERSON SIGNING (PLEASE
         TYPE OR PRINT)