Attachment_A_-_Vendor_App_Packet.pdf

Vendor Application

Please complete, sign and submit along with any corresponding required forms to the school/department requesting the goods or services. NOTE: All new vendors must submit an IRS Form W-9. Additionally, prior to starting work, ALL Services related vendors are required to be “Jessica Lunsford Act” compliant and must submit a Drugfree Workplace Certificate and a Certificate of Insurance.

Incomplete applications will not be processed. For additional information please contact the VCS Purchasing Department at: 386-947-8786 Extension 50855 / PurchasingDept@groups.volusia.k12.fl.us

Possible Conflict of Interest Situations per Florida Statute 112.313 and School Board Policies If you answer "Yes" to any questions below, please contact the Volusia County Schools (VCS) Purchasing Department before completing the rest of the form.

1. Are you requesting a new supplier to be loaded or is this a request to update an existing supplier profile?

NOTE: A government issued, valid form of identification is required for both new Vendor Applications and updates to existing Vendor Applications.

NEW UPDATE

2. Are you an employee of the Volusia County Schools (includes substitutes and community coaches)? YES NO

3. Is any employee of VCS an owner, proprietor, partner, director, or officer of this business? YES NO

4. Is any spouse, parent, or child of any employee of the VCS an owner, proprietor, director or officer of this business? YES NO

If yes, Employee's full name: Relationship to Employee:

General Business Information

FEIN or Social Security Number:

Vendor's Invoicing Name (To allow A/P to accept invoices in this name)

Parent Supplier (If applicable):

Mailing Address:

Address / Attn To Name:

City / County: / State: Zip Code:

Remit to Address: (If different from address above):

Address / Attn To Name:

City / County: / State: Zip Code:

Business Classification: Are you operating as a certified Small Business? (If Yes, you must provide a copy of your SBA, OSD, or other certifying agency certification) Yes No

Check all Socio-Economic Business Classifications that apply:

Business Development Program Disadvantage Business

Service-disable Veteran Owned Small Business

Hub Zone

Veteran Owned

Mentor-Protege Program

Woman Owned

Minority Owned

Vendor Representative Contact Name:

Telephone (include Area Code):

Vendor Representative Title:

Vendor Representative Email Address:

Do you want to receive purchase orders electronically?

YES NO If Yes, please provide the designated email address below:

Fax # (include area code):

Type of Business (Please check focus below and provide a brief description in the space provided)

Corporation Foreign Corporation Foreign Governmental Agency Foreign Individual Foreign Partnership Government Agency Individual Partnership

Description of Goods and/or Services to be provided:

Preferred Method of Payment (Please check all that apply):

Check P-Card

I hereby certify to the best of my knowledge, that the information supplied herein, including all pages attached, 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 known, is now debarred or otherwise ineligible by the School District of Volusia County from bidding to provide materials, supplies, or services to the District or any other governmental agency.

Vendor Signature: Date:

INTERNAL USE ONLY

REQUESTING SCHOOL/DEPARTMENT SECTION (REQUIRED):

By signing and submitting this application, I hereby confirm that the information contained in this application is true, complete, and has been validated by the following authorized vendor representative. ________________Sign Here

Vendor Rep Name: Title: Email: Phone #: Validation Date:

Requestor Name: School/Department:

Requestor Title: Date:

Vendor's Legal Name (To be used on the Purchase Order)

Revised: 06/28/2023 Owner: Purchasing

SCHOOL DISTRICT OF VOLUSIA COUNTY

PURCHASING DEPARTMENT

In accordance with Florida Statute 287.087, whenever two or more bids, proposals, or replies, that are equal with respect to price, quality, and service are received by the State or by any political subdivision for the procurement of commodities or contractual services, a bid, proposal, or reply received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. Established procedures for processing tie bids will be followed if none of the tied vendors have a drug-free workplace program. In order to have a drug-free workplace program, a business shall:

(1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

(2) Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

(3) Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1).

(4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

(5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee’s community by any employee who is so convicted.

(6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.

As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements.

VENDOR’S SIGNATURE DATE

TYPE OR PRINT COMPANY NAME

DRUG-FREE WORKPLACE

CERTIFICATION FORM

State of Florida

Affidavit Regarding the Use of Coercion for Labor and Services

Section 787.06(13), Florida Statutes requires all nongovernmental entities executing, renewing, or extending a contract with a governmental entity to provide an affidavit signed by an officer or representative of the nongovernmental entity under penalty of perjury that the nongovernmental entity does not use coercion for labor or services as defined in that statute.

The School Board of Volusia County, Florida is a governmental entity for purposes of this statute.

As the person authorized to sign on behalf of Respondent, I certify that the company identified does not:

Use or threaten to use physical force against any person;

Restrain, isolate, or confine or threaten to restrain, isolate, or confine any person without lawful authority and against her or his will;

Use lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or services are not respectively limited and defined;

Destroy, conceal, remove, confiscate, withhold, or possess any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person;

Cause or threaten to cause financial harm to any person;

Entice or lure any person by fraud or deceit; or

Provide a controlled substance as outlined in Schedule I or Schedule II of s. 893.03 to any person for the purpose of exploitation of that person.

Respondent Vendor Name:

Vendor FEIN:

Vendor's Authorized Representative Name and Title:

Address:

City: State: ZIP:

Phone Number:

Email Address:

Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.

By:

AUTHORIZED SIGNATURE

Print Name and Title:

Date: