Vendor Business Profile

Phone Number:

Fax Number:

Email Address:

Web Address:

Name: Phone Number:

Title: Email Address:

Name/Title

Date:

Corporate Address:

Vendor Business Profile

Vendor should complete all requested information as indicated by the 'grey' boxes

Identification Information:

Vendor Name (Legal Name & d/b/a):

City, State & Zip Code:

Remit to Address:

2. Is the vendor a 1099 recipient?

City, State & Zip Code:

Contact Information:

Vendor Information:

1. Describe the type of business or service provided:

3. List the Appropriate Federal Tax Classification (Sole

Proprietor, C-Corp, S-Corp, Partnership, LLC, Other)

4. Is the vendor at least 51% owned, controlled and actively managed by a minority person?

If yes to #4, submit the State of Florida MBE/WBE Certification Number

Name of Person at SJR State College Requesting Vendor to Complete the Vendor Business

Profile

If yes to #4, list the appropriate minority classification: (African American, Hispanic, Asian American,

Native American, American Woman, Service Disabled Veteran)

5. Conflicts of Interest: List any state employee who owns, directly or indirectly, an interest of

five percent or greater in the firm or any of its branches

6. List the officers of the corporation, partners or principal members of the

firm and their titles

It is the sole responsibility of the vendor to promptly notify SJR State College with any and 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 Statutes, 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.

All vendors are required to complete this form in its entirety. The vendor is required to submit a valid tax form (W-9) along with the completed Vendor Business Profile Form to

the purchasing department. Forms may be emailed to purchasingdepartment@sjrstate.edu or faxed at 386-312-4167. Please call the purchasing department if you have any

questions 386-312-4200.

Name of Person Completing Form: