Website (If Applicable)
Contact Name
Email Address
Zip Code
State
City
Cell Number
Address
Individual Name
Business Phone
I. Business Information
Business Name/DBA
Vendor/Business Pay Application
Date
II. Tax Filing Status
Check the box that applies to your business and complete the appropriate fields below.
Individual / Sole Proprietor Non-Profit Organization Partnership Corporation
Social Security # Federal Tax ID # DUNS #
III. Business Type
Check if any box applies to your business and enter the certification number.
Local Business DBE
MBE WBE
Certification #
IV. Payments
Provide mailing address for payments if different than the above address.
Remittance Name
Address
City State Zip Code
V. Business License Information
Provide information for all that apply.
Florida State Certified License #
Florida State Registration License #
Florida Local Business Tax Receipt # Lee County Competency (Contractor) License #
I hereby certify that the information supplied herein is correct:
Name
Title
Da
te
Print Form
1
Lee County Board of County Commissioners - Procurement Management
2115 Second Street, 1st Floor - Fort Myers, FL 33901
PO Box 398 - Fort Myers, FL 33902-0398
Phone: (239) 533-8881
Email: procurement@leegov.com
Rev. 01/2020
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