Fillable Vendor Application (Miami-Dade County Public Schools)

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Vendor Application (Miami-Dade County Public Schools)

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Page 1 of 4 FM-3921 Rev. (01-21)
Vendor Application
Miami‐Dade County Public Schools ‐ Procurement Management Services
Interested vendors should fill out the Vendor Application Form and refer to the Procurement website, at
http://procurement.dadeschools.net, for current solicitations. The completed Vendor Application Form should
be e-mailed to vendors@dadeschools.net or mailed to the address listed below:
MIAMI‐DADE COUNTY PUBLIC SCHOOLS
PROCUREMENT MANAGEMENT SERVICES
1450 N.E. 2nd Avenue, Suite 650
Miami, Florida 33132
Tel.: (305) 995‐4288
To minimize delays in processing, please ensure the following documents are submitted along with your vendor
application:
IRS FORM W-9 (Required)
Florida Division of Corporation’ SUNBIZ website screen print showing active or applicable home state
certification of registration to conduct business, as determined by the School Board* (Required)
Latest County Business Tax Receipt (Required)
Latest City Business Tax Receipt (Optional)
The SUNBIZ website (www.sunbiz.org), maintained by the Florida Division of Corporations, will be consulted to
verify the active registration status of the business identified in the vendor application. Delays in processing
may occur if the business name (or fictitious name, if any) does not match the information recorded with the
Florida Division of Corporations. All applicants are required to submit a completed and signed IRS form W‐9,
proof of active status from SUNBIZ and the latest county business tax receipt.
The SAM website (www.sam.gov), maintained by the U.S. Federal government, will be consulted to ensure
there are no related exclusion records in existence. An exclusion record identifies those parties excluded
from receiving Federal contracts, certain subcontracts, and certain types of Federal financial and non‐
Financial assistance and benefits. Exclusions are also referred to as ‘suspensions’ and ‘debarments.’
Page 2 of 4 FM-3921 Rev. (01-21)
Vendor Application
Miami‐Dade County Public Schools ‐ Procurement Management Services
1A. TAXPAYER IDENTIFICATION (REQUIRED)
6. TYPE OF BUSINESS (REQUIRED)
State Incorporated
Corporation
Date Incorporated
Partnership
Sole Proprietorship (One individual owner)
Non-Profit Organization
Joint
Other
(Registered taxpayer I.D. for the business entity ‐ FEIN or SSN, matching
federal tax return)
1B. BUSINESS INFORMATION (REQUIRED)
Fictitious Name (Doing Business As, d.b.a., if any)
7. LICENSES (OPTIONAL)
Occupational License Number (Attach copy)
Issued By
Certificate of Competency (if applicable)
Other Licenses
Name (Business name matching federal tax return will be used to
address purchase orders)
Street Address
City
State
Zip Code
2. MAILING ADDRESS (OPTIONAL)
(If same as section 1B, leave blank, otherwise will be used to address
purchase orders)
Street Address
City
State Zip Code
8. PRIMARY BUSINESS CLASSIFICATION (REQUIRED)
General Contractor
Subcontractor
(Type)
Retailer
Broker
(Type)
Maintenance/Repair
Other
(Type)
Professional Services
(Type)
3. INVOICE REMITTANCE ADDRESS (OPTIONAL)
(If same as section 1B, leave blank. Must match your invoice remittance
address. Will be used to address checks)
Street Address
City
State
Zip Code
4. COMMUNICATION DETAILS (REQUIRED)
Contact Person
Telephone Number
E‐Mail Address (Will be used to email purchase orders)
9. INDUSTRY DESIGNATION
10. M-DCPS CERTIFICATION
800 Number
Fax Number
5. AFFILIATED COMPANIES (REQUIRED)
Name of Affiliated Company
Street Address
State
Zip Code
City
Telephone
Manufacturer/Producer
Dealer or Distributor
For information on becoming a certified Micro/Small,
Minority/Women or Veteran Business Enterprise,
please refer to:
The Office of Economic Opportunity
WEBSITE: oeo.dadeschools.net
PHONE NUMBER: 305-995-1307
LINK: http://oeo.dadeschools.net/#!/fullWidth/1006
Clear Form
SELECT ONE
Page 3 of 4 FM-3921 Rev. (01-21)
11. OWNERSHIP DISCLOSURE (REQUIRED)
If the contract or business transaction is with a corporation, partnership, sole proprietorship, or joint venture, the full legal name and business address
shall be provided for each officer, director, and stockholder or owner, who holds, directly or indirectly, five percent (5%) or more of the stock or ownership.
If the contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and each beneficiary. Post Office
addresses are not acceptable.
12. AGENT, REPRESENTATIVE OR EMPLOYEE AUTHORIZED TO TRANSACT BUSINESS ON BEHALF OF THE ENTITY/FIRM
(REQUIRED)
Name Title Name Title
Name of Company (if other than applicant) Name of Company (if other than applicant)
Street Address Street Address
City State Zip Code City State Zip Code
Telephone Number Telephone Number
13. CATEGORY CODES (REQUIRED)
Using the Category Code List as a reference, please use the spaces below to specify up to 12 unique codes that identify the goods and/or services which
your firm can supply. These codes will be used by the Procurement Department when alerting vendors regarding new opportunities to do business. Only
the 12 unique codes specified on this application will be accepted, any additional codes submitted will not be honored. The Category Code List may be
found at http://procurement.dadeschools.net/pdf/categorycodes.pdf
14. CONE OF SILENCE ‐ BOARD POLICY 6325
The School Board of Miami‐Dade County, Florida, enacts a Cone of Silence from issuance of a solicitation and shall terminate at the time the item is
presented by the Superintendent to the appropriate Board committee immediately prior to the Board meeting at which the Board will award or approve
a contract, reject all bids or responses, or take any other action that ends the solicitation and review process.
Name
Gender
Stock Ownership
Page 4 of 4 FM-3921 Rev. (01-21)
15. LOBBYISTS ‐ BOARD POLICY 8150
School Board Policy 8150, delineates the policy regarding lobbyists. Pursuant to this rule, lobbyists shall complete, annually, a Lobbyist Registration Form,
and pay the annual registration fee.
Pursuant to this rule, every person required to register shall list all individuals who may make a presentation when the person appears as a representative
for an individual or firm for an oral presentation before a site administrator, or instructional personnel, or certification, evaluation, selection, technical
review or similar oral presentation committee. This listing shall include the Clerk's form, the list of presenters, and the indication of fee receipt, prior to
the oral presentation. No person shall appear before any employee or committee on behalf of any individual or firm, unless he or she has been listed as
part of the firm's presentation team or unless he or she is registered with the Clerk's office and has paid all applicable fees.
16. DISCLOSURE OF EMPLOYMENT OF CURRENT AND FORMER SCHOOL BOARD EMPLOYEES ‐ BOARD POLICY 6460
Pursuant to School Board Policy 6460 Business Code of Ethics, all bidders, proposers, consultants, vendors and contractors are required to disclose the
names of any of their current and future employees who serve as agents, principals, subcontractors, employees, or consultants, to work on any agreement
for the bidder, proposer, consultant, vendor, or contractor, and who are currently employed or have been employed by the School Board within the last
two (2) years. Such disclosures will be in accordance with current School Board Policies, but will include, at a minimum, the names of former School Board
employees, a list of the positions the employees held in the last two (2) years of their employment with the School Board, and the dates the employees
held those positions. Written approval by the School Board for the use of current or former School Board employees (within the last two years) is mandatory
prior to using funds obtained from any agreement to subsidize the current or former School Board employees services.
NAME LIST OF POSITIONS DATES EMPLOYEE HELD POSITION
All School Board Policies may be accessed at: http://www.dadeschools.net/schoolboard/rules/
17. ATTESTATION (REQUIRED)
Under penalties of perjury, I certify that:
1) The number shown on this vendor application is my correct taxpayer identification number (or I am waiting for a number to be issued to me) ;
2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service
(IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer
subject to backup withholding. Vendor must cross out Item 2 above if he/she has been notified by the IRS that he/she is currently subject to backup
withholding because of failure to report all interest and dividends on his/her tax return; and
3) I agree with The School Board of Miami‐Dade County, Florida, Business Code of Ethics and agree to comply with this Code and all applicable School Board
contracting and procurement policies and procedures (School Board Policy 6460).
Pursuant to School Board Policy 6460, which may be accessed at http://www.dadeschools.net/schoolboard/rules/, all bidders, proposers, consultants, and
contractors are required to disclose the names of any of their employees who serve as agents or principals for the bidder, proposer or contractor, and
who, within the last two years, have been or are employees of the School Board. Such disclosures will be in accordance with current School Board rules,
but will include, at a minimum, the name of the former School Board employee, a list of the positions the employee held in the last two years of his or her
employment with the School Board, and the dates the employee held those positions.
Pursuant to Florida State Statute 119.071 (5) (2) (a), you are being notified that Procurement Management Services is collecting your social security number
or taxpayer identification number, inasmuch as the Internal Revenue Service requires that this information be obtained to report income paid to you.
CORPORATE SEAL (If appropriate)
Date:
Signature:
NOTE: Failure to complete the sections labeled REQUIRED on this application will result in processing delays.
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Vendor Application (Miami-Dade County Public Schools)

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Completed 2 February 2021

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