2-Compliance Worksheet.pdf

COMPLIANCE INFORMATION SHEET

Formal Company Name:

Business Address:

Web Address:

Type of Business: Sole Proprietorship: ☐ Partnership: ☐ Corporation: ☐ Joint Venture : ☐ LLC ☐ Other (specify):

Registered in Florida (SunBiz) Yes:☐ No:☐ Business Registration State of Origin:

Copy of certification from Florida Secretary of State providing corporate status attached Yes: ☐ No: ☐

Out of State corporation: Florida Business License attached: Yes: ☐ No: ☐

Office Locations: Orange County: ☐ Central Florida: ☐ or contiguous county: ☐ Federal Employer Identification Number: Years in Business:

Number of Active Clients: Number of Inactive Clients:

History of changes to ownership:

License Sanctions (if any):

Debarments (if any):

Financial Stability Compliance & Qualifications Indicate type of supporting document included with your proposal in accordance with Section 3.2.5.

☐ Audited Financial Statements ☐ Dun & Bradstreet Report or SER ☐ CFO/Controller Financial Stability Attestation F.S. 92.525

Authorized Parties Soliciation Contact Information

Name/Title:

Title:

Address:

Legal Notices (if awarded) Name/Title:

Address:

Telephone:

Email:

Principals / Proposers Name/Title:

Address:

Telephone:

Email:

Authorized Contracting Signature (if awarded) Name/Title:

Address:

Telephone:

Email:

Persons authorized for presentations or interviews (include name, title and email address)

If Contractor is provided access to any student personally identifiable information, Contractor acknowledges that it shall comply with the privacy regulations outlined in the Family Educational Rights and Privacy Act (“FERPA”), for the handling of such information, to the extent such regulations apply to the Contractor. Contractor will not disclose or use any student information except to the extent necessary to carry out its contractual obligation(s) under the Agreement if awarded.

Company:

Authorized Representative’s Name and Title:

Authorized Signature: Date:

Email: