Purchasing

vendor application

*Federal I.D. #:
*Company Name:
*Address:
*City:
*State:
*Zip Code:
*Country:
*Phone No.:
 Ex: 954-444-4444
Ext.
Fax No.:
 Ex: 954-444-4444
*E-mail Address:
*Contact Person:
*Title:

*Type of Organization:

Sole Proprietorship Partnership Corporation

If payment is to be mailed to an address different than the above address, please complete the following:

Address:
City:
State:
Zip Code:
Country:
Phone No.:
 Ex: 954-444-4444
Ext.
Fax No.:
 Ex: 954-444-4444
Contact Person:
Title:

Other governmental Entities to which you have sold in the past 2 years

If you currently hold any Florida state contracts, list Numbers and expiration dates.

Contract No.
Expiration Dates
(ex: 01/01/02)

*Principal line of business:
*How long in present business:

CERTIFICATION

I CERTIFY THAT THE INFORMATION SUPPLIED HEREIN IS CORRECT AND THAT NEITHER THE APPLICANT NOR ANY PERSON (OR CONCERN) IN ANY CONNECTION WITH THE APPLICANT AS A PRINCIPAL OR OFFICER, SO FAR AS IS KNOWN, IS NOW DISBARRED OR OTHERWISE DECLARED INELIGIBLE BY ANY PUBLIC AGENCY FROM BIDDING FOR FURNISHING MATERIALS, SUPPLIES OR SERVICES TO ANY AGENCY THEREOF. I ALSO UNDERSTAND THAT ALL CONTACTS WITH THE CITY OF PLANTATION ARE TO BE MADE SOLELY THROUGH THE PURCHASING DIVISION UNLESS OTHERWISE DIRECTED BY THE PURCHASING DIVISION. FOR ADDITIONAL INFORMATION, PLEASE CALL (954) 797-2648.

Check this application to ensure that a correct response has been given to each question. Any omissions will result in follow-up inquiry and delay your entry onto our Bidder's list. Please fill out a W-9 form and fax it to 954-797-2649.

It is understood that failure to bid or return the proper no bid form for any given Commodity Class could result in removal from the Bidder's list for that Class.


* Authorized Name

* Title

* Date (ex:(ex: mm/dd/yyyy)

Comments: