Welcome to the City of Hollywood Procurement Services

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Please fill out the following questions to finish the registration process.
Required fields denoted by *

Correspondence Address (to which bid requests are mailed)

Company Name:*

Street Address:*

P.O. Box #

City:*

State:*

Zip Code:*

Contact Person(if any):

Remittance Address (for payment) Same As Above

Company Name:*

Street Address:*

P.O. Box #

City:*

State:*

Zip Code:*

Contact Person(if any) :

Main Phone:* - -

800 Number: 1- - -

Fax Number: - -

Email Address:*

Social Security Number: - -

Federal ID Number:
This field must be filled in to be registered in the City's internal vendor registration system and to receive bid notifications via mail that are specific to your commodities/services offered.

Type of Organization (check all that apply)

> Dealer
> Individual
> Retailer

> Factory Representative
> Jobber
> Incorporated

> Manufacturer
> Partnership
> in-State

Are you a Minority-Owned or Woman-Owned Business?* Yes No
If Yes, Check the Appropriate Category or Categories Below and Complete 6a:

> African-American
> Native American

> Hispanic
> Woman

> Asian-American
> Disabled

6a.

Is your firm certified as a Minority/Woman Business Enterprise* Yes No
If Yes, Date Certified
Expiration Date:
Name of Agency Certified with:

Invoice Terms/Discount:*

Business Hours:

Locations for Returning Material (include addresses):
For Replacement:
For Repair:
For Credit:

10.

Licenses and Certifications:
City of Hollywood Occupational License #:
Expiration Date:
Broward Country Occupational License Number:
Expiration Date:
Certificate of Competency Number:
Expiration Date:

Additional Licenses / Cetifications:
Type: Number: Issuing Agency:
Expiration Date:

Type: Number: Issuing Agency:
Expiration Date:

11.

Commodity/services provided (please select ALL that apply):
Electronic Registration will result in automatic e-mail notification of bid opportunities in the selected categories. You may select multiple (or all) categories. If no categories are selected, you will be notified of ALL bid opportunities.

For help in selecting which categories best represent your product or service please use our Commodity Category Search.

ALL
01 - Administrative, Financial, and Management Services 02 - Agricultural Equipment and Related Products and Services 03 - Arts, Crafts, Entertainment, Theatre 04 - Automotive Products, Vehicles, and Services 05 - Building Equipment, Supplies, and Services 06 - Clothing, Textiles, Laundry Equipment, and Supplies 07 - Communication Equipment and Services 08 - Computers, Software, Supplies, and Services 09 - Food, Equipment, and Related Services 10 - Furnishings and Related Services	11 - Furniture and Related Services 12 - Hardware, Related Equipment, and Services 13 - Highway Road Equipment, Materials, and Related Equipment 14 - Janitorial and Cleaning Equipment, Supplies, and Services 15 - Laboratory Equipment, Supplies, and Services 16 - Maintenance and Repair of Equipment 17 - Medical Equipment, Supplies, and Services 18 - Miscellaneous Commodities and Services 19 - Office Supplies, Related Items, and Services 20 - Paper, Printing Equipment, and Related Products and Services	21 - Personal Products, Equipment, and Services 22 - Public Works, Park Equipment, and Construction Services 23 - Rental and Leasing Services 24 - Safety and Protection Equipment and Related Services 25 - School and Library Equipment, Supplies, and Services 26 - Sporting, Athletic, and other Outdoor Equipment and Services 27 - Testing and Sampling Equipment and Services 28 - The Trades: Electrical, Engineering, HVAC, Plumbing, and Welding 29 - Transit Equipment and Related Services, Mass 30 - Water and Sewer Treatment Equipment, Supplies, and Services

12.

Liability Insurance:

Carrier:*	Policy Number:*
Expires:*

13.

Worker's Compensation Insurance:
If not applicable type "Not Applicable" for Carrier, "99999" for Policy # and any Expiration date.

Carrier:*	Policy Number:*
Expires:*

14.

Four Commercial References (Include name, address, and phone number)
1.
2.
3.
4.

15.

Company Officers or Principals Who Are City of Hollywood Employees or Related to City of Hollywood Employees:

Name:

Position/Title:

Name:

Position/Title:

Name:

Position/Title:

16.

From time to time the City of Hollywood conducts bids for the sale of surplus items (including used equipment, parts, old vehicles etc.) Please check the box for e-mail notifications regarding bids for the sale of surplus if you are interested.
Yes, I am interested

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