Vendor Certification

Please fill out the following form to begin the registration process. Be sure to complete all of the required information correctly. If any information in each tab is invalid or left blank, your profile may not be processed. Underlined words, indicate additional information viewable by clicking on the word. Should you require assistance, please contact Greg Gould, Vendor Management Specialist, Purchasing Department at 813-745-8511

Fields marked with an * are required for submission.These fields are in most sections please ensure you go through each section thoroughly.

Equal Opportunity Acknowledgement

Moffitt Cancer Center is an equal opportunity employer and federal contractor or subcontractor. Consequently, the parties agree that, as applicable, they will abide by the requirements of 41 CFR 60-1.4(a), 41 CFR 60-300.5(a), and 41 CFR 60-741.5(a) and that these laws are incorporated herein by reference. These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.

I Acknowledge *

Vendor Remit Information

Same as Vendor Information

Business or Payee Name *

Address *

City *

State *

Zip *

Country *

Phone *

Fax *

Conflict of Interest

Does any employee, owner, or representative of Vendor have a personal relationship with Moffitt Staff? *

Yes

Conflict of Interest is a relationship between the vendor employees or representatives and Moffitt staff wherein a personal benefit would result from the business relationship.

HIPAA

Will your organization have access to patient medical information while performing services for the Center? *

Yes

Federal Government Exclusions

Has your organization or any of its owners, board members, or employees been excluded or debarred from Medicare or Federal funds? *

Yes

If yes, provide date and warning:

Has your organization or any of its owners, board members, or employees received a warning letter from Medicare, FDA, or other Federal agencies? *

Yes

If yes, provide date and warning:

Organization Information

Annual Sales

Number of Employees*

Vacation/Holiday Shutdown Schedule

Emergency Contact After Hours, Days, and Weekends

Shifts Worked

Customer Service Location

Organizational Structure

President/CEO/Owner *

Phone Number *

Ext

Chief Operating Officer

Phone Number

Ext

VP Engineering

Phone Number

Ext

VP/CFO/Finance

Phone Number

Ext

VP Manufacturing

Phone Number

Ext

VP Marketing/Sales

Phone Number

Ext

VP Customer Service

Phone Number

Ext

VP Quality

Phone Number

Ext

Legal Counsel

Phone Number

Ext

Sales Director/Manager

Phone Number

Ext

Outside Sales Rep:

Phone Number

Ext

Inside Sales Rep:

Phone Number

Ext

Customer Service Mgr:

Phone Number

Ext

Traffic/Shipping Mgr:

Phone Number

Ext

Corporation * Yes No			Small Business * Yes No
Large Business * Yes No			Government Owned * Yes No
Privately Held * Yes No			Non-Profit * Yes No

Vendor Certification

Equal Opportunity Acknowledgement

Vendor Information

Vendor Remit Information

Business Information

Conflict of Interest

Business Classification

Business Enterprise Certification

HIPAA

Federal Government Exclusions

Organization Information

Organizational Structure

Agreements

Vendor Guidelines