Vendor Certification - H. Lee Moffitt Cancer Center & Research Institute

Vendor Purchase From 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? YesNo

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:

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

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

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.

H. Lee Moffitt Cancer Center & Research Institute

Guidelines for Vendors and Vendor Representatives

Prepared by: