115 Boston Avenue, Suite 2100 • Altamonte Springs, FL 32701 • Tel:407-303-5180 • Fax: 407-303-5181
Vendor Application Materials Management/Purchasing Department         
 
Date of Application:  11/15/2018 Expiration Date:  11/15/2019
Services Provided:
Trade:   

License/Permit No.
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Services: 

License/Permit No.

Exp. Date


 
Products: 
 
License/Permit No.
Exp. Date

Company Name:  
Address: 
City:   State:     Zip:     Tel. No.:   Fax No.:      
Email Address: Website:
Person's Name/Key contact:   Tel. No.:     ext. 
Fax No.:        Email Address:
Legal Form of Organization:   Company Owned by:  
Company is Registered   Year Company founded: Company founded by:    
Annual Gross Sales:   Number of Employees:   Average value of contracts:
Workman's Compensation:   General Liability Insurance:    Financial stability available upon request:
Use Subcontractors:   Company references available upon request: (Yes, authorize's Florida Hospital to contact your references.)
Minority Business Enterprise
Compliance
As an officer, and, or, as a principal of the Company, I do hereby warrant the Company, Company principals, employees, contractors, or sub-contractors, are not presently under exclusion from, nor have ever been excluded from participation in Medicare, Medicaid, or any other Federally funded health care program, pursuant to 42 U.S.C. 1320a-7, nor have been found in violation of any Federal, State, or Local Government Statute or regulation causing exclusion from doing business, nor does it presently employ or contract with any individual or entity that has ever been excluded.
I certify that all of the above information is true and correct.
Print Name: 
Title: 
Signature and Date:   11/15/2018