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Vendor Application
Florida SouthWestern State College
8099 College Parkway
Fort Myers, FL 33919
Phone: (239) 489-9350
Fax: (239)489-9399
purchasing@fsw.edu
To be considered for placement on the FloridaSouthWestern State College vendor list, please complete this application and attach a copy of your current W-9 form
Completion of this form does NOT place your firm on a "Prequalified List". Visit https://www.fsw.edu/procurement for additional Vendor Information
Company Name
Mailing Address
Billing Address
Contact Name/Title
Email Address
Company Webpage Address
Telephone Number
Fax Number
Tax Filling Status: Choose the one that applies
Tax Filling Status: Choose the one that applies
Individual/Sole Proprieter
Non-Profit Organization
Corporation
Other
If Other Checked, please fill out
Federal Tax ID and/or Social Security Number
Briefly Describe Type of Business or Services Provided:
Officers of corporations, partners, or principal members of firm and their titles
Name/Title 1
Name/Title 2
Name/Title 3
Certified Minority Business Enterprise
Certified Minority Business Enterprise
Yes
No
If yes, please check on of the following, and include a copy of your certification with this application
If yes, please check on of the following, and include a copy of your certification with this application
Hispanic
African American
American Indian
Service-Disabled Veteran
Woman Owned
American Indian Alaskan
Asian Pacific American
Other
If Other minority select please enter below
To become certified with the State of Florida, visit
https://osd.dms.state.fl.us
for the Office of Supplier Diversity.
List any State of Florida or other Florida Educational or Government Entity contracts of which your firm is a participant
It is the sole responsibility of the vendor to promptly notify Florida SouthWestern State College with all changes to this application.
Certification: I certify that the information supplied herein (including all attachments) is correct to the best of my knowledge. I further certify that in doing business with the State of Florida, my firm is in compliance with Chapter 112, Florida Statues, conflicts of interest, and that I have disclosed the name of any state employee who owns, directly or indirectly, an interest of five percent or greater in the above firm or any of its branches.
By checking here I certify the above
By checking here I certify the above
Yes
W-9 Attachment/ CMBE Attachment
File attachments associated with the ticket.
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Other Fields
Your name
Your first name
Your last name
Your email address
Verification Code