Vendor Registration

Please complete the following:

1. Name and Address:

Company name

Street address

(or) PO box 

City & State

Zip code

 -

Contact person
2. Telephone Numbers:

Main number

800 number

Fax number

E-mail address

3. Federal ID #

(or) Social Security #

4. Are you a Minority-owned or a Woman-owned business?
Yes No
    If yes, check the appropriate categories below and complete 6a
African-American Hispanic
Asian-American Native American
Women Disabled
5. Is your firm certified as a Minority/Woman Business Enterprise?
Yes No

 If yes:

Date certified

 

Expiration date   

Certified by

Agency applied to

6. Invoice terms/discount
7. Business hours
8. Licenses and Certifications:

Broward Cty Occ Lic #

Expiration date 

Cert of Competency #

Expiration Date
9. Principal Line of Business
10. List all types of commodities and services you can provide and indicate whether a
commodity or service:
11. Company Officials:

Name

Title

Name

Title

Name

Title