Vendor_Information_Form.pdf

PDF 2 MB Posted

Attached to
Substance Abuse Treatment Services 2026
Solicitation number
26-RFP-012
Issued by
Glades County, Brownsville CDP, Florida

About this file

This is a Vendor Information Form issued by the Flagler County Board of County Commissioners Purchasing Department for potential vendors seeking to contract with the county. The form is associated with a Substance Abuse Treatment Services 2026 solicitation issued by the Flagler County Department of Health and Human Services. The department is requesting proposals from local and regional non-profit organizations with experience providing substance use prevention, substance abuse treatment, or related services. Agencies not currently funded by Flagler County Health and Human Services are eligible to apply. No specific response dates, due dates, site visits, or bidder's conferences are referenced in the vendor form itself, though these details would be contained in the full solicitation documents.

The funding for this opportunity is generated from the Alcohol and Drug Abuse Trust, funded through court fees in accordance with Sections 938.13 and 893.165 of Florida Statutes. Proposals must request a minimum of $10,000, with a maximum award of $35,000. Funding will be provided as a one-time award, though a subsequent one-year renewal may be executed if funds become available. The vendor form requires submission of standard documentation including a W-9 form and Certificate of Insurance. Vendors may indicate if they qualify for local vendor preference or Women/Minority Business Enterprise classifications, and must specify whether they accept credit card payments and provide information technology services.

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Text version

Name of Business Entity or Individual:

Doing Business As (DBA) Name; Registered Fictitious, Trade or Assumed:

Tax ID Number: FEIN SSN/ITIN OTHER

Website:

Company/Corporate Address:

Address:

City:

State: Zip:

Phone: Email:

Payment Address (if different from above):

Address:

City:

State: Zip:

Vendor No: Input by:

PURCHASING USE ONLY

FLAGLER COUNTY

BOARD OF COUNTY COMMISSIONERS

PURCHASING DEPARTMENT

VENDOR INFORMATION FORM

Accept Credit Card? Yes _____ No _____

Check any special business classifications that apply to your business. Classifications are subject to approval.

_____ Local Vendor Preference

_____ Women/Minority Business Enterprise

Is Vendor providing a technology (IT) service? Yes _____ No _____

Certificate of Insurance attached? Yes _____ No _____

W9 attached? Yes _____ No _____

Sheet2

Name of Business Entity or Individual:
Doing Business As DBA Name Registered Fictitious Trade or Assumed:
Tax ID Number:
Website:
Address:
City:
State:
Zip:
Phone:
Fax:
Payment Address:
Payment City:
Payment State:
Payment Zip:
Tax Type: Choice1
Yes - Accept Credit Card: Off
No - Do not accept credit cards: Off
Local Vendor Preference: Off
Women/Minority Business Enterprise: Off
Yes, COI Attached: Off
No, COI not attached: Off
Yes, W9 attached: Off
No, W9 not attached: Off
Yes: Off
No: Off

File details come from the government source that posted it. Updated .