OpenGov_Fillable-_Final.pdf

% Days Payment Terms: Net 45 (per Florida Statute F.S. 218.73)

Deposit (if required) has been paid in the amount of $

Proper Corporate Identity is needed for a firm registered with the Florida Division of Corporations. Please visit dos.myflorida.com/sunbiz/ for this information. It is essential to return a copy of your W-9 with your submittal.

I hereby agree to abide by all conditions of this solicitation, including all insurance requirements, and certify that I am authorized to sign this solicitation for the vendor.

Authorized Signature:

Print Name:

Title:

It is the policy of Pinellas County, Board of County Commissioners, to accept the lowest responsive and responsible or highest ranked submittal received meeting specifications. No changes requested by a vendor due to an error in pricing will be considered after the advertised solicitation opening date. By signing this Vendor Submittal Acknowledgment Form, vendors are attesting to their awareness and acceptance of this policy and agreeing to all solicitation of terms and conditions, including any insurance requirements.

Vendor Name (as shown on W-9):

Doing Business As (DBA) (if applicable):

Mailing Address (as shown on W-9):

City, State, Zip (as shown on W-9):

Vendor Email (primary company email):

Remit to address (as shown on vendor invoice):

Federal Tax ID (FEIN) #:

Vendor Contact Information

Contact Name:

Phone Number:

Email Address:

VENDOR SUBMITTAL ACKNOWLEDGEMENT FORM

THIS FORM MUST BE RETURNED WITH YOUR RESPONSE

bcc105507 Sticky Note Accepted set by bcc105507 bcc105507 Sticky Note Accepted set by bcc105507

Company Name:

Business Address:

Length of time the company has been in business:

How long in present location:

Total number of current employees: Full-Time: Part-Time:

Number of employees you plan to use to service this contract:

All references will be contacted by a County Designee via email, fax, or phone call to obtain answers to questions, as applicable before an evaluation decision is made. Vendor must have experience in work of the same or similar nature, and must provide references that will satisfy the County. Proposer must furnish a reference list of at least four (4) customers for whom they have performed similar services.

REFERENCE 1: REFERENCE 2:

Company:

Address:

Telephone:

Contact Name:

Contact Email:

Company Email:

REFERENCE 3: REFERENCE 4:

Company:

Address:

Telephone:

Contact Name:

Contact Email:

Company Email:

Company:

Address:

Telephone:

Contact Name:

Contact Email:

Company Email:

Address:

Telephone:

Contact Name:

Contact Email:

Company Email:

Company:

CONTRACTOR REFERENCES

THIS FORM MUST BE RETURNED WITH YOUR RESPONSE

ELECTRONIC PAYMENT (EPAYABLES)

Pinellas County, Board of County Commissioners, is offering faster payments. The County would prefer to make payment using credit card through the ePayables system.

Would your company accept to participate in the ePayables credit card program?

Yes No

For more information about ePayables credit card program please visit the Purchasing Department website:

https://pinellas.gov/epayables-2/

Company Name:

Phone Number:

Email:

Signature:

Print Name:

THIS FORM MUST BE RETURNED WITH YOUR RESPONSE

https://pinellas.gov/epayables-2/