Vendor Registration

2. Date Submitted*
4. Full Legal or Parent Company Name*
6. Additional Company Name or “Doing Business As”
8. Physical Street Address of Business*
10. Mailing Address or P.O. Box Number
12. Tax I.D. Number*
14. Contact Information
16. Contact Name*
18. Title*
20. Company Phone Number
22. Company Fax Number
24. Contact Cell Phone Number*
26. Email Address*
28. Are you or any other officer, owner, member, etc. currently employed by City of Fort Pierce?

    1. YES
    2. NO
30. If yes, please provide the following information:
    
32. Full Name
34. City/Department/Position
36. Company Name
38. Products/Services Provided
    Please indicate all products, materials, and/or services that your company can legally provide.
    (i.e. electrician services, plumbing supplies, mowing services, small engine parts, engine repairs, handyman services, etc.)*
40. 
    All vendors are required to be properly licensed with a current active license in City of Fort Pierce and/or with the State of Florida, as required by law.
42. If your company provides services/repairs outside of your physical business location (i.e. mobile services, any construction-related service, etc.) The City of Fort Pierce requires that proof of insurance is provided before any work can be performed. Insurance is not required for the purchase and delivery of parts, goods, or materials. It is the responsibility of the vendor to provide updated insurance certification upon expiration.
44. 
    City of Fort Pierce’s Minimum Required Insurance Limits
46. General Liability: $1,000,000 per Occurrence and $2,000,000 General Aggregate
    Automobile Liability: $1,000,000 Combine Single Limit
    Worker’s Compensation: Per Florida Statue with $500,000 Employees Liability (or) properly issued current Exemption Certificate issued by the State of Florida
48. 
    If required, all insurance certificates including the above limits must show the certificate holder as follows:
50. City of Fort Pierce
    Attn: Purchasing Department
    P.O. Box 1480
    Fort Pierce, FL 34954-1480
52. 
    Current License *
54. Current Insurance Certificates Attached (If required)
56. W-9 Form*
58. 
    By submitting this form you are electronically signing the City of Fort Pierce's Vendor Registration Form.
Leave This Blank:


59. Submit

* indicates a required field