Third Party Provider Applicaiton
General InformationOrganization Name: / Click here to enter text.
Contact Name: / Click here to enter text.
Address: / Click here to enter text.
Address Line 2: / Click here to enter text.
City: / Click here to enter text. / State: / Click here to enter text. / Zip: / Click here to enter text.
Phone: / Click here to enter text. / Email: / Click here to enter text.
Company URL: / Click here to enter text.
Year Established: / Click here to enter text. / Number of Employees: / Click here to enter text.
Do you have professional liability insurance or the equivalent? / Yes / ☐ / No / ☐
Please indicate the region(s) in Florida in which you are willing to work:
All ☐ / 1 ☐ / 2 ☐ / 3 ☐4 ☐ / 5 ☐ / 6 ☐ / 7 ☐
Please provide a descriptive summary of your areas of expertise, capabilities, and services you most often provide::
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Please list the industry(s) in which you have worked.
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Please indicate how many different clients you have served as a consultant in the past two years and what types of projects.
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How did you first hear about FloridaMakes?
☐ / Referral / ☐ / Advertisement in: Click here to enter text.
☐ / From a FloridaMakes staff member / ☐ / A trade show or other event
☐ / Media (news or social) / ☐ / A FloridaMakes event
☐ / Other: Click here to enter text.
Attachments: You may attach additional materials, but please no more than 5 pages. Return this completed application and attachments to
References: Please provide at least two references including at least one client reference whom you have served as a consultant. Please have your references email the “Reference Questionnaire” to
Thank you for your interest in working with FloridaMakes
FloridaMakes Third Party Provider Package Page 3 of 3