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 Robert Sandlin, Vendor Management Specialist, Purchasing Department at 813-745-4666

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. These regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability. The parties also agree that, as applicable, they will abide by the requirements of Executive Order 13496 (29 CFR Part 471, Appendix A to Subpart A), relating to the notice of employee rights under federal labor laws.

I Acknowledge

Vendor Remit Information

Same as Vendor Information
Business or Payee Name:*
Address:*
City:*
State:*
(Foreign Vendors: Please select "FO" in this field)
Zip:*
Country:*
Phone:*
Fax:*

Business Information

Federal ID or SS#:*

Start of Business:

Open the calendar popup.

Years in Present Location:
Do you have a former business name?
Current or Previous Business with Moffitt?
Equipped for EDI Transactions (electronic data interchange) transmissions through GHX (Global Healthcare Exchange)?
Which Credit Cards are Accepted:
1. Visa
  MasterCard
  American Express
Are you Submitting:
1. Literature
  Brochures
  Line Card
Dun & Bradstreet #:
NAICS Code:
Description of Products/Services Business Offers:*
Do you have a Doing Business as (DBA) name? Yes
No

Conflict of Interest

Yes	No
		* Does any employee, owner, board member, or any other representative of Vendor have a personal relationship with the Moffitt Staff (Employee , Physician , Researcher or Board Member)? 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. A conflict of interest does not preclude a business relationship but must be disclosed.

Supplier Diversity
Business Ownership Information

The business must be at least 51% or more managed and controlled by the diversity classification selected and the majority owner/partner is “Involved in the management and daily operations of the business”.

Yes	No		Yes	No
		*Minority-Owned Business Enterprise (MBE)			*Woman-Owned Business Enterprise (WBE)
		*Veteran-owned Business Enterprise (VBE)			*Non-profit
		*Service Disabled Veteran-owned Business Enterprise (SDVBE)			*SBA (8A) Certified Small Business
		*SBA HUBZone Certified Small Business			*Certified Small Disadvantaged Business

Please select the diversity category of the majority owner of the business below:

Diversity Category: African American
Hispanic American
Asian American
Native American

Non-Profit


Yes	No		Yes	No
		Non-Profit Minority Board			Historically Black Colleges & Universities (HBCU)
		Non-Profit Minority Employees			Non-Profit Minority Community

Certification
Yes	No
	*	Is your business certified as Minority, Woman-Owned, SBA (8A) or Small Disadvantaged Business by a certifying agency, or verified/certified as a Veteran-owned or Service Disabled Veteran-owned Business Enterprise by the U.S. Dept. of Veterans Affairs or the State of Florida Office of Supplier Diversity?

HIPAA

Yes	No
		* In the performance of Service for the Center, would your organization have access to patient medical information?

Federal Government Exclusions

Moffitt Cancer Center will screen all vendors and its senior management through the OIG (Office of Inspector General) and GSA (General Services Administration) databases. Any potential matches must be cleared by obtaining additional information from the organization or individual.

Yes	No
		* Has the organization or any of its owners, board of directors, or employees been excluded, sanctioned or otherwise debarred from billing or receiving Medicare or Federal Government Agency Funds.
		* Has the organization or any of its owners, board of directors, or employees been issued a warning letter by Medicare, the FDA (Federal Drug Administration), or any other Federal Government Agency ?

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:

Guidelines for Vendors and Vendor Representatives

Prepared by: