Vendor Certification

Vendor Purchase Form Information

Business or Payee Name: *
Vendor Category: *
Address:*
City:*
State:*
(Foreign Vendors: Please select "FO" in this field)
Zip:*
Country:*
Business or Payee Email:
Business or Payee Website Address:
Phone:*
Fax:*
Contact Person:*
Contact E-mail:*
Contact Phone:*
Please let us know what prompted you to register your business with Moffitt:*

Notified by Purchasing
Community or MWBE Organization
Monitoring Moffitt Website
Advertisement
Bid/RFP
Vendor Conference/Outreach Event
Other Please Describe here:

Discounted Payment Terms?

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 #:
SIC 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

Yes	No		Yes	No
		*Minority-Owned			*Woman-Owned
		*Veteran			*Non-profit
		*Service Disabled Veteran			*SBA (8A) Certified Small Business
		*SBA HUBZone Certified Small Business			Certified Small Disadvantaged Business

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?

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

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