DATE: ________________________

Please answer the following questions regarding your business. From the information given, we will add to the City's vendor database for bidding purposes. It is preferred that you type or print your responses as to avoid possible errors in transcription. Mail application to: City of Fort Pierce, Purchasing Department, P.O. Box 1480, Fort Pierce, Florida 34954-1480.

Business name:_____________________________________________
Address:___________________________________________________
City/State/Zip:______________________________________________

Mailing address (if different):__________________________________

Telephone number: (_____) _____ - _____

Fax Machine number: (_____) _____ - _____

Business Classification for Tax Purposes: ________________________
Corporation Tax I.D.# _________________________
Partnership Tax I.D.# _________________________
Other (explain) Tax I.D.# _________________________

Are you a City of Fort Pierce Employee at the present time? _________
If yes, enter the following information:
S.S.# _______________________________________________________
Name: ______________________________________________________
Department: _________________________________________________

Do you have an Affirmative Action Program? __________

Do you have a Drug Free Work Place Program? __________

Business Type:
Minority __________
Female __________
Labor Surplus __________
Large __________
Small __________
Small Disadvantaged __________
Socially and Economically Disadvantaged __________

Service/Commodity: ______________________________________________

I certify that the information supplied herein (including all papers attached) is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principle or officer, so far as it is known, is now debarred or otherwise declared ineligible by any agency of the City from bidding for furnishing materials, supplies or services to the City or any other agency thereof.

Signature of person authorized to sign this application:

_____________________________________________

Name and Title of Person Signing:

_____________________________________________

Date:

_____________________________________________

Upon completion of application, e-mail to DemandStar.com by Onvia:

supplierservices@onvia.com