| I. Business Information |
| *Company Name | |
| *Contact Person: | |
| Title: | |
| *Street Address: | |
| Suite No: | |
| |
| *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) |
|
| |
| 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) |
| | |
