Submit response to:
FAX #: 561-835-1956 - or -
EMAIL: Subject: Vendor Information
NAME OF FIRM, COMPANY, ORGANIZATION:
NAME OF CONTACT PERSON: / TITLE:
PHONE NUMBER: / FAX NUMBER: / EMAIL:
MAILING ADDRESS:
CITY: / STATE: / ZIP CODE:
SERVICES PROVIDED:
FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN): / STATE OF FLORIDA BUSINESS LICENSE NUMBER (If applicable):
DO NOT include Social Security number with this form; CSC will obtain if/when contracted.
ORGANIZATION STRUCTURE (Please check one):
Corporation ☐ Partnership ☐ Proprietorship ☐ Joint Venture ☐ Other ☐
If Corporation, please provide the following:
(A) Date of incorporation (B) State or Country of incorporation:
W/MBE CERTIFICATION (If applicable): ☐ Minority-Owned Business: ☐ Male ☐ Female
☐ Woman-Owned Business
Please check appropriate box below, if Minority as defined as defined by the State of Florida as: Minority.- a “minority” or “minority person” means a lawful, permanent resident of Florida who is:
☐ An African American, a person having origins in any of the black racial groups of the African Diaspora, regardless of cultural origin.
☐ A Hispanic American, a person of Spanish or Portuguese culture with origins in Spain, Portugal, Mexico, South America, Central America, or the Caribbean, regardless of race.
☐ An Asian American, a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands, including the Hawaiian Islands before 1778.
☐ A Native American, a person who has origins in any of the Indian Tribes of North America before 1835, upon presentation of proper documentation thereof as established by rule of the Department of Management Services.
☐ An American woman.
SMALL BUSINESS OR VETERAN (If applicable): ☐ Small Business: ☐ Male ☐ Female
☐ Veteran: ☐ Male ☐ Female
The undersigned does hereby declare that the statements contained in this form are true, accurate and complete and include all material information necessary to identify and explain the ownership and operation of business. The undersigned understands that all documents submitted will become public record. Further, the undersigned acknowledges on behalf of the consultant, contractor, or vendor, that the business is ready, willing and able to perform work for CSC.
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Authorized Signature (Manual) Authorized Signature (Print or Type) Title (Print or Type)
COMPLETE & PRINT FORMS; SIGN; FAX or SCAN INTO PDF FORMAT AND EMAIL TO CSC AS NOTED ABOVE
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