Fillable Vendor Registration Form (Eastern Florida State College)

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Vendor Registration Form (Eastern Florida State College)

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In compliance with FL Statutes 119.071(5), the
Notification of Social Security Number Collection and
Usage document serves to notify you of the purpose
for the collection and usage of your SSN.
Primary Business Activity / Main Products Sold or Services Offered:
Please use our products/services codes, this will allow a better match of products/services.
Enter all codes applicable to your business. (
EFSC Database
Diversity as a Minority/Woman/Service-Disabled Owned Business?
Optional: Please check one
Service-Disabled Veteran
Hispanic American
Black American
Native Hawaiian
Asian American
Native American
American Woman
Corporation
Sole Proprietor Partnership
Yes
No
Is
your company certified by the State of Florida’s Office of Supplier
Status:
M/WBE and SDVBE9
.
Please type or print your responses to the applicable items below. Your responses will assist us in
evaluating your firm for future bid opportunities and ensure that a check payment is correctly issued.
b.
Issue Checks to:
(pay to the order of)
Corporate Name:
a.
Street / P.O. Box
Contact Person
City
Zip + 4
State
Title
Website Home Page
E-Mail Address
Telephone #
Fax #
Toll-Free #
Street / P.O. Box
Ci
ty
State
Zip + 4
Street / P.O. Box
City
State
Zip
+
4
Telephone #
Fax #
Company Name
Invoices must be submitted
using the name in 1b
1.
Mailing Address
2.
Purchase Orders will be
sent to this address
Contact Person
3.
Contact for quotes, etc.
Contact Information
.
4
Internet & Telephone
Payment Address
Where to send payments
see section 1b above
5
.
Corporate Headquarters
If different from above
address see section 1a
above
.
6
Only one required
LLC
Social Security Number
Federal Employer Identification Number
Type of Business:
IRS required information:
8.
7
Toll-Free #
Telephone # Fax #
Toll-Free #
.
Vendor Registration Form
Procurement Services
1519 Clearlake Rd.
Cocoa, FL 32922
EFSC Procurement Use Only:
Date: Banner
http://www.easternflorida.edu/go/procurement/ Fax this form and a completed W-9 to: 321-433-7371
July 2015
Notification of Social Security Number
Collection and Usage
In compliance with FL Statute 119.071(5), this document serves to notify you of the
purpose for the collection and usage of your Social Security Number (SSN).
Pursuant to Florida Statute, 119.971(5)(a)2.a., Eastern Florida State College collects
and uses your Social Security number for the following purpose in performance of the
College’s duties and responsibilities.
Procurement Services Department
Your SSN is used for legitimate business purposes in compliance with:
1. Completing and processing the Federal 1099 Form (Internal Revenue
Service)
2. Collecting contractor SSN information in order to file the required information
returns with the IRS, as required by federal law (Internal Revenue Code 1609)
In lieu of a Federal Employment Identification Number (FEIN), providing your Social
Security number is a condition of doing business with Eastern Florida State College. To
protect your identity your SSN will be secured from unofficial access, and never
released to unauthorized parties. Using this SSN, EFSC will assign to you a unique
vendor identification number. This unique ID number will be used for all associated
business purposes at the College.
Please direct any questions to the Procurement Services Department at 433-7371.
Products and Services
This is a general list of products and services used by the college. When completing your Vendor
Application Form, please use the numeric codes in this document that best describes your business.
Multiple codes can be entered.
CODEDESCRIPTION OF PRODUCTS/SERVICES
1
ACCREDITATION FEES
2
ADVERTISING
3
ARCHITECTURAL ENGINEERING SERVICES
4
ARCHITECTURAL MASTER PLANNING
5
ARTIST FEES & INTERIOR DESIGN
6
ATHLETIC MATERIALS AND SUPPLIES
7
ATHLETIC UNIFORMS
8
AUDITING FEES
9
AUTOMOTIVE MATERIALS SUPPLIES (FLUIDS, PAPER MATS/SEAT COVERS, PAINT)
10
BACKSTAGE SUPPLIES (THEATER)
11
BANKING SERVICES
12
BINDING (BOOKS, PRINTED DOCUMENTS)
13
BOOKS
14
CATERING SUPPLIES
15
CIGNA DENTAL PREMIUMS
16
COMMISIONS AGENT BOOKING
17
COMPUTER EQUIPMENT
18
CONST & MAINT EQUIPMENT (EQUIPMENT USED BY CARPENTERS, PAINTERS,
ELECTRICIANS, PLUMBERS, METAL WORKERS, MASONS, AND MECHANICS.)
19
CONSTRUCTION MATERIALS (LUMBER, PAINT, FLOOR COVERINGS, ASPHALT AND
GRAVEL, PLUMBING, MASONRY PRODUCTS, GLASS, DOORS, SHEET METAL, ETC.)
20
CONSTRUCTION MATERIALS SUPPLIES
21
CONSULTANT FEES
22
CONTRACTED CUSTODIAL SERVICES
23
CONTRACTED INSTRUCTIONAL SERVICES
24
CONTRACTED ACCOUNTING SERVICES
25
CONTRACTED ADVERTISING SERVICES
26
CONTRACTED FIRE & SECURITY SERVICES
27
CONTRACTED ENGINEERING SERVICES
28
CONTRACTED TRAVEL SERVICES
29
CONTRACTED NON INSTRUCTIONAL SVC
30
DATA SOFTWARE ADMIN NON CAPITALIZED
31
DATA SOFTWARE EDUC NON CAPITALIZED
32
DENTAL INSURANCE
33
DEPARTMENTAL UNIFORMS/PROMOTIONAL WEAR
34
DIPLOMAS AND COVERS
35
E RESOURCES LICENSED
36
E RESOURCES PURCHASED
37
EDUCATIONAL EQUIPMENT
38
EDUCATIONAL FURNITURE
39
EDUCATIONAL MATERIALS SUPPLIES
40
ELECTRICITY
41
EQUIPMENT LEASES (CONSTRUCTION, LAWN, LIGHTING)
42
FOOD PRODUCTS AND FOOD SERVICES
43
FREIGHT AND POSTAGE
44
FUEL VEHICULAR
45
GARBAGE AND COLLECTIONS
46
GENERAL CONSTRUCTION (SITE CLEANUP AND CONSTRUCTION MGT)
47 GROUNDS EQUIPMENT/MATERIALS/SUPPLIES AND LAWN SERVICES (LAWN EQUIPMENT,
FERTILIZER, AND PLANTS)
48
HAZARDOUS MATERIAL NON INSTRUCTIONAL
49
HAZARDOUS MATERIALS INSTRUCTIONAL
50
HAZARDOUS WASTE REMOVEL
51
HEALTH INSURANCE & HEALTH SERVICES
52
HEATING FUELS
53
HONORARIA FEES
54
INSTITUTIONAL MEMBERSHIP
55
INSURANCE GENERAL LIABILITY
56
INSURANCE PROPERTY
57
INSURANCE STUDENT
58
JANITORIAL MATERIALS SUPPLIES
59
LEGAL FEES
60
LIFE INSURANCE PREMIUMS
61
LOCAL TELEPHONE - FAX SERVICES
62
MAINTENANCE MATERIALS SUPPLIES (CONSTRUCTION OR BUILDING
MAINTAINANCE)
63
MAINTENANCE SUPPLIES (CONSTRUCTION EQUIPMENT)
64
MARKETING-SIGNS/POSTERS/TOURING SHOWS
65
MARKETING-PRINT ADVERTISING
66
MARKETING-RADIO ADVERTISING
67
MARKETING-TELEVISION ADVERTISING
68
MATERIALS AND SUPPLIES - OTHER (EXPENDABLE - RATHER REPLACE THAN FIX)
69
MATERIALS TESTING INSPECTION
70
MINOR COMPUTER EQUIPMENT (LESS THAN $1,000)
71
MINOR EQUIPMENT
72
MUSICIANS
73
OFFICE EQUIPMENT
74
OFFICE FURNITURE
75
OFFICE MATERIALS AND SUPPLIES (NON-INSTRUCTIONAL USE)
76
OTHER COMMUNICATION SERVICES
77
OTHER LIBRARY COLLECTION MATERIALS
78
OTHER PROFESSIONAL SERVICES
79
PERIODICALS (MAGAZINES/NEWSPAPERS - CONSUMER AND BUSINESS)
80
PERMITS FEES
81
PRINTING/DUPLICATING/SCANNING SERIVCES
82
RENOVATION AND REMODELING (EXTERIOR AND INTERIOR)
83
RENTALS COPY MACHINES
84
RENTALS EQUIPMENT (FORKLIFT, BACKHOES, TRUCK, TOOLS)
85
RENTALS FACILITIES
86
RENTALS OTHER
87
ROYALTIES
88
SUBSCRIPTIONS/PERIODICAL/VIDEO DISKS
89
SUBSCRIPTIONS
90
SURVEY TEST BORINGS
91
TRAVEL
92
VEHICLES
93
VIDEO CONFERENCING/VIDEO SERVICES
94
VISION INSURANCE
95
W
ATER AND SEWER
96
W
IRELESS COMMUNICATIONS
95
WATER AND SEWER
96
WIRELESS COMMUNICATIONS
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Vendor Registration Form (Eastern Florida State College)

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Completed 23 July 2020

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