Fillable FLORIDA POLYTECHNIC UNIVERSITY SUPPLIER APPLICATION (Florida Polytechnic University)

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FLORIDA POLYTECHNIC UNIVERSITY SUPPLIER APPLICATION (Florida Polytechnic University)

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  • 28 check-boxes
  • 98 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Florida Polytechnic University

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FLORIDA POLYTECHNIC UNIVERSITY
FINANCE & ADMINISTRATION SUPPLIER MANAGEMENT
4700 RESEARCH WAY LAKELAND, FL 33805
(863) 874-8418 ADDSUPPLIER@FLORIDAPOLY.EDU
SUPPLIER APPLICATION
NEW APPLICATION
CHANGE OF INFORMATION
BUSINESS NAME OR PAYEE
AS SHOW ON TAX RETURN
DBA NAME
DOING BUSINESS AS
CONTACT INFORMATION
ACCOUNT INFORMATION
BILLING PHONE #
CONTACT NAME
TYPE
LANDLINE
FAX
MOBILE
LANDLINE
FAX
MOBILE
TAX AUTHORITY FORM REQUESTED
1042-S 1099 TDS
FEDERAL TAXPAYER IDENTIFICATION #
FEDERAL ID TYPE
EIN
SSN
TAX STATUS
INDIVIDUAL (W-9 REQUIRED)
US CITIZEN OR US RESIDENT
US COMPANY (W-9 REQUIRED)
C-CORP, S-CORP, LLC, LLP, LC, LP
US COMPANY (W-9 REQUIRED)
LLC, SOLE PROPRIETOR, PARTNERSHIP
FOREIGN (W-8 REQUIRED)
INDIVIDUAL, COMPANY
PREFERRED PAYMENT TYPE
CHECK EFT/ACH
PREFERRED PURCHASE ORDER DELIVERY
EMAIL FAX
SA VERSION 3 PAGE 1 OF 2
WEB ADDRESS
ZIP
ADDRESS LINE 2
ADDRESS LINE 3
CITY
REMIT TO EMAIL ADDRESS
USED FOR PAYMENT PRENOTIFICATIONS
STATE
BILLING EMAIL ADDRESS
USED FOR EMAILING PURCHASE ORDERS
ADDRESS LINE 1
ADDRESS LINE 2
ADDRESS LINE 3
CITY
REMIT PHONE #
CONTACT NAME
TYPE
ADDRESS LINE 1
REMIT PAYMENT ADDRESS
ZIP
STATE
COUNTRY
BILLING/STREET ADDRESS
COUNTRY
YES
NO
ATTORNEY
DIVERSITY BUSINESS ENTERPRI SE
GOVERNMENT
MINORITY
NON PROFIT
OUTSIDE PARTY
SMALL BUSINESS
WOMAN OWNED BUSINESS
DUNS NUMBER
CUSTOMER ACCOUNT NUMBER
SUPPLIER GROUP
SEND FORM
FEDERAL TAXPAYER IDENTIFICATION #
DOES YOUR BUSINESS QUALIFY AS ANY OF THE FOLLOWING?
SMALL AND/OR MINORITY STATUS INFORMATION
SELECT ALL THAT APPLY
FEDERAL CLASSIFICATIONS
STATE OF FLORIDA CERTIFIED
MINORITY BUSINESS ENTERPRISES (CMBE)
AFRICAN AMERICAN
AMERICAN WOMAN
ASIAN/HAWAIIAN
HISPANIC
NATIVE AMERICAN
SERVICE DISABLED VETERAN
OTHER:
OTHER:
NON-MINORITY (LARGE BUSINESS)
HUBZONE CERTIFICATION
MINORITY OWN BUSINESS
SBA 8(A) CERTIFICATION
SERVICE DISABLED VETERAN
SMALL DISADVANTAGED BUSINESS
VETERAN
VIETNAM VETERAN
WOMEN-OWNED BUSINESS
OTHER:
NON-CERTIFIED MINORITY
BUSINESS ENTERPRISES (NMBE)
NON-PROFIT ORGANIZATION
AFRICAN AMERICAN
MINORITY BOARD OF DIRECTORS
AMERICAN WOMAN
MINORITY COMMUNITY SERVED
ASIAN/HAWAIIAN
MINORITY EMPLOYEES
HISPANIC
OTHER:
NATIVE AMERICAN
OTHER:
IF YOU SELECTED A CLASSFICIATION THAT IS CERTIFIED BY A FEDERAL OR STATE AGENCY,
PLEASE SUPPLY THE FOLLOWING INFORMATION FOR EACH CERTIFICATION SELECTED:
CERTIFICATION NAME CERTIFICATION AGENCY
CERTIFICATION # EXPIRATION DATE
FEDERAL SIZE STANDARD
TO DETERMINE YOUR FEDERAL SMALL BUSINESS SIZE, PLEASE ACCESS THE U.S. SMALL BUSINESS ADMINISTRATION’S WEBSITE
HTTP://WWW.SBA.GOV/ OR VISIT THE SBA’S HTTP://WWW.SBA.GOV/SIZE/ TO LOOK UP
YOUR NORTH AMERICAN INDUSTRY
CLASSIFICATION SYSTEM (NAICS) CODE AND THE QUALIFYING NUMBER OF EMPLOYEE’S OR ANNUAL DOLLAR AMOUNT
IF YOU ARE USING FEDERAL SIZE STANDARDS, PLEASE ENTER THE FOLLOWING INFORMATION:
NAICS CODE NUMBER OF EMPLOYEES
ANNUAL AMOUNT $
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 FLORIDA POLYTECHNIC UNIVERSITY, I OR MY
ORGANIZATION IS IN COMPLIANCE WITH CHAPTER 112, FLORIDA STATUTES, CONFLICT
OF INTEREST, AND THAT I
HAVE DISCLOSED THE NAME OF ANY FLORIDA POLYTECHNIC UNIVERSITY EMPLOYEE WHO OWNS, DIRECTLY OR
INDIRECTLY, AN INTEREST OF 5% OR MORE IN THE ABOVE ORGANIZATION OR ANY OF ITS BRANCHES.
I FURTHER CERTIFY THAT I AM NOT AN EMPLOYEE OF FLORIDA POLYTECHNIC UNIVERSITY.
NAME OF PERSON COMPLETING FORM
FLORIDA POLYTECHNIC UNIVERSITY CONTACT NAME
DATE
OR
CERTIFICATION
SIGNATURE OF PERSON COMPLETING/AUTHORIZING APPLICATION
SA VERSION 3 PAGE 2 OF 2
SEND FORM
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FLORIDA POLYTECHNIC UNIVERSITY SUPPLIER APPLICATION (Florida Polytechnic University)

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Completed 15 August 2020

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