Miami Children's Hospital


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Vendor Registration

E-MAIL TO A FRIEND

All sections must be completed in order to become a registered vendor with Miami Children's Hospital. If you have any questions regarding the completion of this application, please call Materiel Services at (305) 662-8226.

Bold fields are required.

New Application Update/Revision Re-Registration

SECTION 1: VENDOR INFORMATION Use this section to indicate your company name, the address to corporate office, primary telephone number, toll free telephone number, after hours telephone number, facsimile number, e mail address (confirmation and notification purposes), website address and contact name.
Name of Company (Full Legal Name)
Parent Company or DBA (Doing Business as)
Address
City
State	Zip Code
County
Phone	ext.
Toll Free Phone	ext.
Alternative Phone
Fax
Contact Person
Email
Web Address (URL)
Tax ID #

SECTION 2: TYPE OF BUSINESS ORGANIZATION Please check all applicable.
	Corporation - Incorporated in the State of
	Publicly Traded Corporation
	Partnership
	Sole Proprietorship (One individual owner)
	Not-for-Profit Organization
Other (Specify)

SECTION 3: OWNER'S NAME If applicant is a firm, partnership, or association, provide the full name and title of each member. If applicant is a corporation, provide the full name and title of Directors, Officers, President, Vice President, Secretary and Treasurer. Attach additional sheets, if necessary.
Name	Title
Name	Title

SECTION 4: VENDOR REMIT TO INFORMATION Use this section to indicate the Remit to information.
Click here if Same As Section 1.
Remit to Name
Remit to Address
City
State	Zip Code
Phone	ext.
Fax
Contact Person

SECTION 5: VENDOR TERMS INFORMATION Use this section to indicate if your firm accepts purchase orders via facsimile, has electronic ordering, invoicing, remittance capabilities, standard invoice terms, normal lead times and whether or not there is a charge for delivery.
Does your firm accept purchase orders via facsimile transmission?	YesNo
If yes, what is the fax number?
Does your firm have electronic ordering capabilities?	YesNo
Does your firm have electronic remittance capabilities?	YesNo
If yes to either electronic question, please mail electronic specifications to Materiel Services separately
Standard Invoice terms
NET days
Discount %
Discount Days
Delivery Information
Normal Delivery Days
Rush Delivery Day
Free Delivery	YesNo
Restock Charges	$
Est. Delivery Fees	$

PLEASE NOTE: ALL INVOICES MUST HAVE A PO# REFERENCED FOR PAYMENT.
All invoices and statements should be sent to:
Miami Children's Hospital
Attn: Accounts Payable
3100 S.W. 62nd Ave.
Miami, Fl. 33155

SECTION 6: VENDOR QUOTATION/BID INFORMATION Use this section to indicate the contact information to be used by the Miami Children's Hospital for Bid/quotation purposes.
Click here if Same As Section 1.
Contact Person
Address
City
State	Zip Code
Phone	ext.
Fax

SECTION 7: RELATIVES/EMPLOYEES OF MCH List Company Officers or Principals who are Miami Children's Hospital Employees or Related to Miami Children's Hospital Employees: IF COMPANY EMPLOYS MCH EMPLOYEE OR RELATIVE OF MCH EMPLOYEE, THIS INFORMATION MUST BE DISCLOSED. (Attach additional sheets, if necessary.)
None

Name	Position/Title
Department	Relationship

Name	Position/Title
Department	Relationship

Name	Position/Title
Department	Relationship

Name	Position/Title
Department	Relationship

SECTION 8: VENDOR OCCUPATIONAL LICENSE INFORMATION Use this section to indicate license number and expiration date.
Not Applicable
County Occupational License
License Number
County
Expiration Date	mm/dd/yyyy
Other License Type
Type
License Number
County
Expiration Date	mm/dd/yyyy

Type
License Number
County
Expiration Date	mm/dd/yyyy

SECTION 9: VENDOR INSURANCE INFORMATION Use this section to indicate insurance information.
Liability Insurance
Carrier
Policy Number
Expiration Date	mm/dd/yyyy
Worker's Compensation
Carrier
Policy Number
Expiration Date	mm/dd/yyyy

NOTE: Should an agreement be entered into between the parties, vendor will need to provide a Certificate of Insurance naming Miami Children's Hospital as an additional insured.

SECTION 10: MINORITY BUSINESS ENTERPRISE DECLARATION Use this section if you wish to be certified as a minority-owned or woman-owned business.
DEFINITIONS: Black persons having origins in any of the Black African racial groups; Hispanic persons of Mexican, Puerto Rican, Dominican, Cuban, Central or South America of either Indian or Hispanic origin, regardless of race; Native American or Alaskan native persons having origins in any of the original peoples of North America; Asian and Pacific Islander persons having origins in any of the Far East countries, south East Asia, the Indian subcontinent or the Pacific Islands.
Is at least 51% of your company owned, operated and managed by anyone of the ethnic groups as defined above?	YesNo
Is at least 51% of your company owned, operated and managed by a Caucasian Female?	YesNo
Company Name
Contact Person
Address
City
State	Zip Code
Phone
Fax