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. Please note the form cannot be saved during the submission process. Should you require assistance, please contact the Purchasing Department at 813-745-7840.

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

Vendor Information
Vendor Remit Information
Business Information
Conflict of Interest
Business Classification
Supplier Diversity
HIPAA
Federal Government Exclusions
Organization Information
Organizational Structure
Agreements

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.

April 2014

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27	28	29	30	1	2	3
4	5	6	7	8	9	10

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.

Business Classification

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

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:

Agreements

As a vendor for H. Lee Moffitt Cancer Center, your organization and its products and services purchased will be required to adhere to the following. Please indicate your acceptance to the following:

Yes	No	N/A
			*Standard Purchase Order Terms and Conditions - (Applicable except if transaction specific agreement in writing exists)
			*Moffitt Policy ADM-V001 Vendor/Contractor Guidelines
			*Corporate Compliance - Standards and regulations administered by local, state, and federal agencies.
			*Certificate of Insurance Type of Insurance -Workers Compensation Minimum Statutory Limits -Comprehensive General Liability, Bodily Injury, & Property Damage -Automobile Liability Insurance Bodily Injury, & Property Damage
			*Equipment Purchases -National Bureau of Fire Underwriters -National Electronic code NFPA 70 -Life Safety Code NFPA 101 -Need FDA Approval, if applicable to application
			*Construction Transactions Subject to the following: -Standard Building Code -Standard Mechanical Code -Standard Plumbing Code -D.C.C. Florida Board of Building Codes & Standard Accessibility Requirements Manual -American National Standard Institute for Handicapped -Standard Gas Code -National Fire Protection Association -Fire Protection Rules & Regulations of the State Fire Marshall -AHCA Agency for Health Care Administration

Guidelines for Vendors and Vendor Representatives

In order to ensure a mutually successful business relationship, a brochure that outlines general business guidelines has been developed. The brochure can be obtained at any of the Centers Check-in desks or by clicking here

Yes	No
		*As a vendor for the Center, your organization and its representatives agree to abide by the guidelines for Vendors and Vendor Representatives?
		*Is Vendor registered with the state of Florida to collect sales use tax?
		*A specific assignment of copyright will be required for vendor to execute identifying copyright materials. Is vendor willing to assign right/title/interest, and all copyrights in any work preformed to Moffitt Cancer Center?
		*By entering your name, you assert that the responses to this questionnaire are true and accurate. Providing incorrect answers could disqualify the company as a vendor for Moffitt.

Prepared by:

Name:*
Title:*

Minority Business Enterprise (MBE): An enterprise that is at least 51% owned and controlled by minority group members, or, in the case of a publicly-owned business, at least 51% of the stock is owned by minority group members. The recognized minority groups consist of the following:

African-Americans/Black
- All persons whose origins are in any Black racial groups of Africa.
Hispanic Americans
- All persons of Mexican, Puerto Rican, Cuban, Central, Latin, or South American, Portuguese, or other Spanish origins, regardless of race.
Asian/Indian Americans
- All persons having origins in India, Pakistan, or Bangladesh.
Asian/Pacific Americans
- All persons having origins in any of the peoples of Japan, China, Vietnam, Korea, Samoa, Guam, U.S. Trust Territories of the Pacific Islands. Northern Mariana Islands, Laos, Cambodia, or Taiwan.
American Indian
- All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliations or Eskimos, Aleuts, and native Hawaiians.

Women-Owned Business Enterprises (WBE): An enterprise that, regardless of ethnic background, is at least 51% owned and controlled by women members, or, in the case of publicly-owned business, at least 51% of the stock is owned by women.

Please use the available field to list your certifying agency. Moffitt accepts both certified and uncertified MBE and WBE businesses. If a business is uncertified, we do encourage certification, which is available at no cost through the following agencies:

City of Tampa’s Women / Minority Business Enterprise Program
Hillsborough County’s Disadvantaged Minority / Disadvantaged Women Business Enterprise Program
State of Florida Department of Management Services, Office of Supplier Diversity