Fillable Supplier Diversity Small Business Program/ Application (Broward College)

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Supplier Diversity Small Business Program/ Application (Broward College)

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Office of Supplier Relations and Diversity
6400 NW 6
th
Way, 2
nd
Floor
Fort Lauderdale, Florida 33309
Phone: 954-201-7455
Fax: 954-201-7330
SDC@broward.edu
SUPPLIER DIVERSITY SMALL BUSINESS
PROGRAM APPLICATION
OFFICE OF SUPPLIER RELATIONS AND DIVERSITY
Eligibility Requirements:
1. Business must be geographically located in Broward, Palm Beach or Miami-Dade County to be
considered eligible to participate in the Supplier Diversity Small Business Program.
2. Business must be certified by one of the following agencies and organizations:
Broward County Government
Florida State Minority Supplier Development Council (FSMSDC)
Miami-Dade County Government
Palm Beach County Government
School Board of Broward County
State of Florida
Women Business Enterprise National Council - Florida (WBENC)
3. Submit the completed Supplier Diversity Small Business Program Application and a current
certification from one of the above agencies/organizations. The certification must be valid for at least
90 days before expiration.
4. Maximin annual gross sales average over 3 years:
Construction Service ($10,000,000.00)
General Service and Commodity ($5,000,000.00)
Goods & Supplies ($5,000,000.00)
Professional Service ($5,000,000.00)
START SUCCEED SOAR
Form SDSB-4 (Rev. 7/2020) 2 | Page
OFFICE OF SUPPLIER RELATIONS AND DIVERSITY
SUPPLIER DIVERSITY SMALL BUSINESS PROGRAM APPLICATION
PLEASE READ CAREFULLY - TYPE OR PRINT - ANSWER ALL QUESTIONS –
ATTACH ADDITIONAL INFORMATION
Section I - Principal Place of Business
Company Name (must be same name used for vendor registration):
d/b/a:
Street Address (Must be same name used for Supplier registration):
P.O. Box:
City:
State:
Zip Code:
County:
Telephone Number:
Alternate Phone Number:
Fax Number:
E-mail Address:
Website:
Race and Gender of Principal Owner(s):
Note: Ownership and race must equal 100%
Business Owner Name:
Ownership
%
Race
% of
Race
Gender
Asian American
African American
Hispanic American
Native American
White (Non-Hispanic)
Other (specify)______
☐ Male ☐ Female
Asian American
African American
Hispanic American
Native American
White (Non-Hispanic)
Other (specify)______
☐ Male ☐ Female
Asian American
African American
Hispanic American
Native American
White (Non-Hispanic)
Other (specify)______
☐ Male ☐ Female
Asian American
African American
Hispanic American
Native American
White (Non-Hispanic)
Other (specify)______
☐ Male ☐ Female
Total:
Form SDSB-4 (Rev. 7/2020) 3 | Page
Section II – Certification
A. Is the company certified? ☐ Yes
☐ No
B. Submit a copy of the current certification from one of the following agencies and organizations. The
certification must be valid for at least 90 days before expiration:
Broward County Government
Florida State Minority Supplier Development Council (FSMSDC)
Miami-Dade County Government
Palm Beach County Government
School Board of Broward County
State of Florida
Women Business Enterprise National Council - Florida (WBENC)
C. If certified
, please provide:
1. Certifying Agency Name: ___________________________________________________
2. Type of Certification (i.e., MBE/WBE/SBE/DBE): __________________________________
3. Expiration Date: _________________________________________________________
4. Attach copy of certification certificate.
Section II
I – Business Information
A. Annual gro
ss sales averaged over the previous three years:
YEARS
ANNUAL GROSS SALES
ANNUAL GROSS SALES AVERAGED OVER 3 YEARS
1.
2.
3.
B. Business Type – Select the business type that applies to your business entity.
☐ Construction ($10,000,000.00)
☐ Professional Services ($5,000,000.00)
☐ Nonprofessional ($5,000,000.00)
☐ Goods & Services ($5,000,000.00)
C. Commodity - List all the products or services offered by your company.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Form SDSB-4 (Rev. 7/2020) 4 | Page
Section IV – Geographic Markets Serviced by Your Company
NUMBER OF EMPLOYEES
COUNTIES
STATES
Section V – Bonding Capacity: $ ________________
Section VI - Company References – (Please provide 3 references.)
COMPANY NAME
CONTACT NAME/TITLE
ADDRESS
PHONE #
EMAIL
1.
2.
3.
It is recognized and acknowledged that the statements contained in this application are true and that any material
misrepresentation will be grounds for denial of participation in the Broward College’s Supplier Diversity Small Business Program.
Misrepresentation may result forfeiture of awards or termination of contracts, which may be awarded as the result of the
information contained in this application.
I hereby authorize the Broward College Office of Supplier Relations and Diversity to verify the accuracy of the statements made in
this APPLICATION to determine whether my company meets the requirements established for participation in the Broward College
Supplier Diversity Small Business Program.
Note: Application must be signed by company owner.
__________________________________________ _____________________________________________
Signature Print Name
__________________________________________ _____________________________________________
Title Date
Submit the completed Supplier Diversity Small Business Program Application and additional documents to:
Broward College
Office of Supplier Relations and Diversity
6400 NW 6
th
Way, 2
nd
Floor
Fort Lauderdale, Florida 33309
Fax: 954-201-7330
Email SDC@Broward.edu
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Supplier Diversity Small Business Program Application (Broward College)

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Completed 28 January 2021

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