Supplier Registration Form

Required Fields are Bold

Section I. Business Information

Company Information

Company Name:
Physical Address:
 
City:
Country:
State:
Zip:
Phone Number:  Ext.
Fax Number:
 
Remit To Address:
 
City:
Country:
State:
Zip:
Phone Number:  Ext.
Fax Number:

Contact Information

Contact Name:
Title:
Phone Number:  Ext. 
Fax Number:
E-Mail Address:
Company Website (URL):
 
Emergency Contact Name:
Title:
Phone Number:  Ext. 
Cell Phone Number:

Company Data

Business Type:
Geographical Service Area:
Year Business was Established:
Number of Employees:
DUN and Bradstreet Number:
Primary SIC Code(s):    

Products and/or Services

Select NAICS Code(s)
To remove items from the list above, highlight the NAICS code and click Remove From List button.
 
Select Commodity Code(s)
To remove items from the list above, highlight the Commodity Code and click Remove From List button
 
Enter your business description.(up to 500 characters)

Annual Sales Volume

(numbers only, no comma or decimal point. I.E., 3000000)
2014
2013
2012

References

List two current business customers (local or otherwise) which have been or are now your customers:
Company Name Contact Name Phone Number

Section II. Discounts and Terms

Standard Terms:
Discount off Published List Price:
Educational Discounts:
Are you a general services administration vendor?
If Yes, attach a list of current agreements:

Section III. Tax Information

Federal ID:
Completed W-9, copy of social security card, alien registration card, or visa:
Tax Reporting Name (DBA):
 
1099 Tax Reporting:
(Select all that apply.)
 
If exempt from 1099 reporting, select your qualifying exemption reason:

Section IV. Type of Ownership

Legal Structure:
 
Are you a citizen or permanent resident?
Country of Residence:
State/country where services will be provided:
 
Country of Incorporation:
State/country where services will be provided:

Section V. Officers

PositionNameEmailPhone NumberPercentage
Owner
President
Vice President
Treasurer
Secretary

Section VI. Owner Identification

Certification

Is your business presently certified by one of the following organizations:
  1. An Affiliate of the National Minority Supplier Development Council (NMSDC).
  2. An Affiliate of the Women's Business Enterprise National Council
  3. The Federal Government, or
  4. A State or Local Government Agency (Considered on a case-by-case basis).
 
Are you SBA CCR listed?
If yes, what is your CAGE code:
 
Certification Type (1)
Certifying Agency
Certification No.
Expiration Date   (MM/DD/YYYY)
Upload Certificate
Certification Type (2)
Certifying Agency
Certification No.
Expiration Date   (MM/DD/YYYY)
Upload Certificate
Certification Type (3)
Certifying Agency
Certification No.
Expiration Date   (MM/DD/YYYY)
Upload Certificate

Business Concern

If Minority Owned:

Section VII. Certification

University of Miami Participation

Are you or any member of your family an employee of the University of Miami?
If yes, enter name and social security number.
Last NameFirst NameM.I.SSN
 
Are any significant stock holder (10% or more of the current authorized stock), partners or employees in a decision making capacity of your organization employees of the University of Miami?
If yes, enter name and social security number.
Last NameFirst NameM.I.SSN
 
Are any family members of those indentified above employees of the University of Miami?
If yes, enter name and social security number.
Last NameFirst NameM.I.SSN

Debarment

Under penalties of perjury, vendor certifies that it is not debarred, suspended, or ineligible party as defined in the rules implementing Executive Order 12549 and agrees to notify immediately if it is placed on the List of Parties Excluded from Federal Procurement or Non-procurement Programs.

Protected Health Information

To extent vendor will have or be given access to Protected Health Information as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as part of performing services hereunder, vendor will be deemed a Business Associate of University for purposes of this Agreement and will comply with all requirements of a Business Associate under HIPAA and/or any Addendum to this Agreement which University may provide.

Medicare/Medicaid/Federal Healthcare Programs

Vendor represents and warrants that Vendor or anyone with a direct or indirect ownership control (interest) has never been (1) convicted of a criminal offense related to health care and / or related to the provision of services paid for by Medicare, Medicaid or another federal health care program; or (2) excluded from participation in any federal health care program, including Medicare and Medicaid. Vendor is required to immediately notify the University if any of the foregoing conditions occure. The University reserves the right to terminate this agreement immediately upon notification by Vendor, or discovery by the University, that any of the foregoing conditions occured.

Equal Employment Opportunity And Civil Rights

All Vendors of the University of Miami shall comply, and have complied with all State, Federal and local laws, regulations, or orders applicable to the purchase, manufacture, processing and delivery of materials, including but not limited to the Fair Labor Standards Act of 1938, as amended. The Equal Opportunity Clause contained in Section 202 of Executive Order 11246 and the Affirmative Action Clauses contained in 41 CFR Section 60-250 and 41 CFR Section 60.741 implementing the requirements of the Vietnam Era Veterans Readjustment Assistance Act of 1974 and the Rehabilitation Act of 1973 are hereby incorporated by reference in any subsequent purchase order or other contract between parties.

The undersigned certifies to the University of Miami that it does not maintain and provide for its employees any segregated facilities in any of its establishments and that it does not permit its employees to perform their services at any location under its control where segregated facilities are maintained. The undersigned further agrees that he or she will obtain identical certification from his or her subcontractors prior to the award of subcontracts exceeding $10,000 that are not exempt from the provisions of the equal opportunity clause and will retain such certification in its files.

The undersigned certifies to the University of Miami that if the undersigned has 50 or more employees and a contract/subcontract with the University of Miami for the furnishing of supplies or services or the use of real or personal property in the amount of $50,000 or more that it has developed and is maintaining written affirmative action plans for each of its establishments as required by OFCCP regulations 41 C.F.R. Section 60-1.40, 60-250.5 and 60-741.5.

Section VIII. e-Business Readiness

Are you registered with Ariba? Do you have an online catalog?
Can you sell your products/services online? Are you Electronic Data Interchange (EDI) capable?
 

The undersigned does hereby certify that the foregoing and subsequent statements are true and correct and include all material necessary to identify and explain the operations as well as the ownership thereof. The undersigned agrees to provide the University of Miami Purchasing Department with current, complete, and accurate information on any project on which it works, and any proposed changes in any contractual agreement. Any misrepresentation will be ground for terminating any contract which may be awarded in relaince hereon.

Additionally, submission of this form does not automatically guarantee you future business. Should your application be approved, you will be notified by the University of Miami.

 
Authorized by:
Phone Number:
Email Address: