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Supplier Application Fillable PDF

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Purchasing ∙ 1200 W International Speedway Blvd ∙ Daytona Beach ∙ FL ∙ 32114 ∙ Phone 386/506-3004 ∙ Fax 386/506-4289
rev. 11/24/14
Supplier Application
PART 1 of 3
Daytona State College must have accurate and complete supplier information on file in order to generate a purchase order
and facilitate prompt payment. Please complete the Supplier Application, Supplier Commodity List and W-9 (Part 3 of 3).
Daytona State College offers the option for suppliers to receive electronic payments. To participate complete the Supplier
Authorization for Electronic Funds Transfer form.
References Provide three (3) institutions that are in an active status with the Company (preferably colleges/universities).
Company Name Contact Phone
1
2
3
I certify the above information is correct.
Print Name Signature Date
Return completed documents by email or fax. Email: Procurement@DaytonaState.edu Fax: 386/506-4289
Company Information
Company Name
Business Address
City, ST, Zip
Billing Address
City, ST, Zip
Contact Information
Name
Email
Phone
Fax
Preferred Method to Receive Purchase Order
Fax
US Postal Service
Email
(provide):
General Information
Years in business with the above name.
years
Company’s previous name.
N/A
Company is certified by Office of Supplier Diversity. If yes, attach
certificate.
Yes
No
Company accepts credit cards.
Yes
No
Company agrees to accept Purchase Orders.
Note: Yes indicates
Company agrees to Daytona State College terms and conditions.
Yes
No
Is the Company wholly/partly owned by a Daytona State College:
a) employee, b) trustee, c) or related to an employee or trustee?
Yes
No
If yes, provide the following:
Name
Relationship
Check All That Apply
Type of Business
Corporation
Government
Manufacturer
Non-Profit
Partnership
Sole Proprietor
Minority Categories
African American
American Indian/Alaskan
Asian/Pacific Islander
Hispanic
Service Disabled Veteran
Woman Owned
Purchasing ∙ 1200 W International Speedway Blvd ∙ Daytona Beach ∙ FL ∙ 32114 ∙ Phone 386/506-3004 ∙ Fax 386/506-4289
rev. 11/24/14
Supplier Commodity List
PART 2 of 3
Please check the goods/services offered by your company.
Advertising 011 Lighting Fixtures & Lamps 460
Animals 490 Linens/Linen Services 760
Appliances, Household 730 Maintenance & Repair Services 050
Athletic & Recreation Equipment 830 Material Handling Equipment 690
Awards & Promo Items 940 Medical Equipment & Supplies 470
Audio & Visual Equipment & Supplies 660 Moving & Storage 033
Business & Other Support Services 030 Musical Instruments 810
Chemicals & Chemical Products 510 Office Machines/Equipment 210
Childcare Services 065 Office Supplies 220
Cleaning Equipment & Supplies 890 Paper & Related Products 230
Communication Equipment & Supplies 630 Photographic Equipment & Supplies 650
Computer Accessories & Cables 610 Photographic Supplies & Materials 651
Computer Hardware 600 Plumbing Supplies & Materials 300
Computer Software 620 Printing Services 090
Construction & Building Materials 380 Professional Associations 020
Construction & Building Trade Services 070 Professional Services 010
Custodial Services 061 Publishing Company 965
Direct Mail Services 031 Pumps & Compressors 280
Educational Institutions 041 Refrigeration, HVAC & Heating 080
Educational Materials 040 Safety Equipment 260
Electronic Equipment 110 Scientific Equipment & Supplies 480
Electrical Wire & Power Dist. Equipment 440 Security Services 270
Food Prep & Serving Equipment 750 Subscriptions 961
Freight Forwarder/Custom Broker 032 Tools 320
Furniture Business & Home 710 Uniforms, Clothing, etc. 850
Gases 520 Vehicle Accessories & Parts 140
Government Agency 021 Vehicle Repair 141
Hotels, Motels, etc. 720 Vehicles, Trailers, Cycles & Trucks 120
ID Cards, Decals & Signage 910 Other: Specify Below 960
Keys & Locks 950
Landscaping Services & Supplies 060
Purchasing ∙ 1200 W International Speedway Blvd ∙ Daytona Beach ∙ FL ∙ 32114 ∙ Phone 386/506-3004 ∙ Fax 386/506-4289
rev. 11/24/14
Supplier Authorization for
Electronic Funds Transfer
OPTIONAL
Daytona State College offers payments through Automated Clearing House. Payments will be sent as electronic
funds transfer (EFT) directly to the company’s bank account, eliminating costs and security issues with handling,
depositing and clearing checks.
The supplier will receive an email or fax notification when an EFT payment is submitted, which includes the
invoice(s) paid and total dollars credited to the bank account. We require the following information and signature
to set up the company for EFT payments.
Note: This document will be kept on file for Daytona State College audit purposes.
1. Deposit Account Number
2. Bank Routing or ABA Number
3. Company Name on Bank Account
4. Company Contact Name
5. Telephone Number
6. Fax Number
7 Email for Payment Notification
I authorize Daytona State College to make EFT payments to our company using the information
indicated above.
Print Name Authorized Signature Date
Purchasing ∙ 1200 W International Speedway Blvd ∙ Daytona Beach ∙ FL ∙ 32114 ∙ Phone 386/506-3004 ∙ Fax 386/506-4289
rev. 11/24/14
Purchasing ∙ 1200 W International Speedway Blvd ∙ Daytona Beach ∙ FL ∙ 32114 ∙ Phone 386/506-3004 ∙ Fax 386/506-4289
rev. 11/24/14
PURCHASE ORDER TERMS and CONDITIONS
Daytona State College prohibits the inclusion of any additional or different terms by Seller in the Seller’s acceptance or acknowledgement of this order. The
inclusion of such terms by the Seller will be void, such terms will not be conditions or additional terms to this order, and Buyer’s acceptance of Seller’s goods shall
not be deemed as acceptance of such terms. The terms or conditions from a relevant invitation to bid, proposal or quote are incorporated herein by this reference.
Unless otherwise stated on the face of this order, the following terms and conditions shall apply.
Terms of Payment: Normal terms of payment shall be “Net 30 Days” from receipt of goods and supplier’s invoice in duplicate. Alternative terms of payment
may be considered when in the best interest of the college.
Invoicing: Itemized invoices in duplicate, each bearing the Purchase Order Number must be mailed no later than the day of shipment. If the College is
responsible for transportation costs, a bill of lading or express receipt must be attached to your invoice. Show our purchase order number immediately following
our name.
Discounts: On any discount, time will be computed from date of satisfactory delivery of goods, or from date correct invoice received, whichever is the later date.
Packing and Shipping: An itemized list of contents must be placed in each package bearing the Purchase Order Number. All expenses incurred by Seller’s
failure to furnish necessary shipping documents shall be charged to the Seller.
Law and Regulations: Seller shall comply with all applicable Federal, State and Local laws, statutes and ordinances including, but in no way limited to rules,
regulations and standards of the Occupational Safety and Health Act of 1970 and the Federal Contract Work Hours and Safety Standards Act, and the rules and
regulations promulgated under these acts. Seller agrees, in connection with performance of this order, not to discriminate against any employee or applicant
because of race, sex, religion, color, age, national origin, disability, or marital status.
Patents: Seller agrees to indemnify and hold harmless the buyer, its officers, employees, agents or representatives using the goods specified herein from any
loss, damage or injury arising out of claim or suit at law or equity for actual or alleged infringement of letters patent, by reason of the buying, selling or using the
goods supplied under this order, and will assume the defense of any and all suits and will pay all costs and expenses incidental thereto.
Conflict of Interest: The purchase hereunder is subject to the provisions of Chapter 112 Florida Statutes. All sellers must disclose the name of any director or
agent who is an employee of the college.
Insurance and Indemnification: Seller agrees to indemnify and hold harmless the Buyer, its officer’s agents and employees from and against any and all
claims and liabilities (including expenses) for injury or death of persons or damage to any property which may result, in whole or in part, from any act or omission
on the part of the Seller, its agents, employees or representatives, or arising from any Seller-furnished goods or services, except to the extent that such damage is
due solely and directly to the negligence of the Buyer. Seller shall carry comprehensive general liability insurance, including contractual and product liability
coverage, with minimum limits acceptable to the Buyer. Seller shall, at the request of the Buyer, supply certificates evidencing such coverage.
Risk of Loss: Seller assumes the following risks: (a) all risks of loss or damage to all goods, work in process, materials and other things
until the delivery thereof as herein provided; (b) all risks of loss or damage to third persons and their property until the delivery of all the goods as herein
provided; (c) all risks of loss or damage to any property received by Seller from or held by Seller or its supplier for the account of Buyer, until such property has
been delivered to Buyer; (d) all risks of loss or damage to the goods or any part thereof rejected by Buyer, from the time of shipment thereof to Seller until
redelivery thereof to Buyer.
Inspections and Testing: Buyer shall have the right to expedite, inspect and test any of the goods or work covered by this purchase order prior to shipment.
All goods are also subject to Buyer’s inspection and approval upon arrival. If rejected, pickup/return of the goods will be at the Seller’s expense. Such inspection,
or the waiver thereof, however, shall not relieve the Seller from full responsibility for furnishing goods and work conforming to the requirements of the order, not
prejudice any claim, right or privilege the Buyer may have because of the use of defective or unsatisfactory goods or work.
Termination for Default: Buyer may terminate all or any part of this purchase order by giving notice of default to Seller, if Seller (a) refuses or fails to deliver
the goods within the time specified; (b) fails to comply with any of the provisions of this order or so fails to make progress as to endanger performances
hereunder, or; (c) becomes insolvent or subject to proceedings under any law relating to bankruptcy, insolvency, or the relief of debtors. In the event of
termination for default, Buyer’s liability shall be limited to the payment for goods delivered and accepted by the Buyer under this order.
Stop Work Order: Buyer may, at any time, by written notice to the Seller, stop all or any part of the work. Upon receipt of such notice, the Seller shall take all
reasonable steps to minimize the incurrence of costs during the period of work stoppage. Buyer may subsequently either cancel the stop work order resulting in
an equitable adjustment in the delivery schedule and/or the price, or terminate the work in accordance with the provisions of the order.
Assignment and Subcontracting: Seller shall not assign or subcontract any portion of this purchase order without the prior written approval of the Buyer.
Contractors are encouraged to utilize the E-Verify system to verify the employment eligibility of their employees and subcontractors.
Warranty: By accepting this order, the Seller warrants that the goods furnished hereunder shall be free from latent and patent defects and in full conformity
with the specifications, drawings and/or samples. The Seller also warrants that the goods are fit for the Buyer’s purpose if indicated hereon or in any documents
attached or made a part hereof by reference or if known to the Seller. These warranties shall survive acceptance of and payment for goods received. Failure of the
Buyer to reject said goods shall not constitute a waiver of any of these warranties. The Seller, further shall hold harmless, the Buyer, its customers and any users,
from any loss, damage and expense whatsoever, including attorney’s fees and court costs which may be suffered by breach of any of these warranties.
Delivery:
IF DELIVERY TO DESTINATION CANNOT BE MADE ON OR BEFORE THE SPECIFIED DATE, THE SELLER MUST NOTIFY DAYTONA STATE COLLEGE
PURCHASING DEPARTMENT PROMPTLY.
Corrections/Changes: Clerical errors are subject to correction by the Buyer, but the purchase order may not otherwise be modified or rescinded without Buyer’s
consent. Questions concerning this order may be made by writing to: DAYTONA STATE COLLEGE, Purchasing Department, PO Box 2811, Daytona Beach, FL
32120-2811; by phone (386) 506-3004; or fax (386) 506-4289.
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Completed 6 November 2019

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