Business Data

Date of Application:

Name of Firm:

Principal Contact for Firm:

Years in Business:

Street Address: (Include Suite / Building Number):

City:

State:

Zip:

Mailing Address: (If Different Than Street Address):

Mailing City:

Mailing State:

Mailing Zip:

Phone (Include Area Code):

Fax (Include Area Code):

Email/Website:

Is the principal contact listed above authorized to sign bids, quotes, contracts and checks?

Yes

If no, list name of individual who has such authority:

Phone (Include Area Code):

Federal ID or Social Security Number:

Occupational License Number:

State Contractor's License Number:

Primary Business (e.g., Contractor):

Officers, Owners, Partners

Name 1:

Title 1:

Name 2:

Title 2:

Name 3:

Title 3:

Are any officers, owners, or partners listed above employees of the Pinellas County Sheriff's Office?

Yes

Independently Owned:

Yes

Subsidiary, Affiliate or Division of:

Certified Minority Enterprise?

Yes (check appropriate options below)

Woman-Owned

Hispanic

Native American

African American

Asian American

Native Alaskan

Terms for Payment:

Number of Employees:

Bonding Capacity:

Don't Know

Under $100,000

Over $100,000

Certification
I certify that the information supplied herein is correct and that neither the applicant nor any person (or concern) in any connection with the applicant as a principal officer, so far as is known, is now debarred or otherwise ineligible by the sheriff's office to bid on furnished materials, supplies, or services for the sheriff's office or any city, municipality, or county of the State of Florida.

Signature:

Title:

Date:

Please enter the code above (case sensitive!)

*-Required Field

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