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.

Name

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

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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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