Vendors

Contact Information

Your Name(Required)

First Last

President/CEO/General Manager Name

Email(Required)

President/CEO/General Manager Phone

Phone(Required)

Fax

President/CEO/General Manager Email

Company Description

Provide a brief description of service(s)/product(s) offered(Required)

Tax Filing Status(Required)

Sole Proprietor

Corporation

LLC

S-Corp

Partnership

Company Federal Tax Id Number(Required)

State of Incorporation(Required)

State

Nonprofit?(Required)

Yes

Ownership(Required)

Domestic

Foreign Owned

Number of Employees(Required)

Is your company owned by a parent company?(Required)

Yes

Parent Company Name(Required)

Parent Company Address(Required)

Parent Company Federal Tax ID Number(Required)

Did your company have a name change in the past 12 months?(Required)

Yes

Previous Name(Required)

Method of delivery (Suppliers only) - Check all that apply

Company Vehicle

UPS

FedEx

USPS

Common Carrier

Other

Are you a...?(Required)

Small Business

Minority-Owned Business

Veteran-Owned Business

Woman-Owned Business

Veteran Disabled-Owned Business

None of the above

Description of Products/Services (Short Narrative)(Required)

Licensing Information

State of Florida License Number

Lee County Business Tax Receipt Number

State/County Contractor License Number

Other Licensing

What percentage of present work is?

Government

Please enter a number from 0 to 100.

Commercial

Please enter a number from 0 to 100.

Nonprofit

Please enter a number from 0 to 100.

Other

Please enter a number from 0 to 100.

Total

Insurance Information

Insurance Provider

Insurance Company Phone Number

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Insurance Liability Cover Limits

Worker's Compensation Coverage

Reference #1

Reference Company #1 Name(Required)

Reference Company #1 Phone Number

Reference Company #1 Contact Person

Reference Company #1 Email Address

Reference #2

Reference Company #2 Name(Required)

Reference Company #2 Phone Number

Reference Company #2 Contact Person

Reference Company #2 Email Address

Reference #3

Reference Company #3 Name

Reference Company #3 Phone Number

Reference Company #3 Contact Person

Reference Company #3 Email Address

CERTIFY(Required)

Agree

I certify that all the information above is true. If any of the information provided if found to be false, I understand that the application will be disqualified from consideration.

This field is for validation purposes and should be left unchanged.

Vendor Application

Company Information

Contact Information

Company Description

Licensing Information

What percentage of present work is?

Insurance Information

Reference #1

Reference #2

Reference #3

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