Free DR-415 - Florida

Application for Department of Revenue Approved Bidder's List

DR-45 R.07/97

Thefollowinginformationissubmittedforthepurposeofestablishingtheapplicant'squalificationsandability tosatisfactorilyperformcontractworkintheStateofFloridaforcountypropertyappraisers,taxcollectorsorcounty commissions. Wherenecessary,supplementalexplanationsandschedulesshouldbesubmitted.TheDepartmentofRevenue mayrequestsuchadditionalmaterialanddataasitdeemsnecessarytoestablishthequalificationsandcapabilitiesofthe applicant.Thisapplicationmustbecompletedinitsentirety.Foranyportionwhichdoesnotapply,placeappropriateN/A inthespaceprovided. Identification FirmName Established State FederalEINumber SSNifIndividual
Social Security Numbers are used by the Florida Department of Revenue as unique identifiers for the administration of Florida's taxes. Social Security Numbers obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records.

BusinessOrganizedAs: ResidentAgent

( (

) Individual ) Corporation

( (

) Partnership(GeneralorLimited) ) Other-Specify

(

) JointVenture

(Name)

(Address)

Ifyourbusinessisaforeigncorporationorforeignlimitedpartnership,proofmustbefurnishedthatyouarequalifiedthroughtheFloridaSecretaryofState'sOfficetodobusinessinFlorida. OfficeAddress City State Zip

MailingAddressforOfficialCorrespondence(Ifdifferentfromabove) City BusinessTelephone State Zip

(AreaCode)

(Number)

Checkthefollowingareasinwhichyouarerequestingtobeplacedontheapprovedbidder'slist.Foreacharea checked,providedetaileddocumentationintheremainderoftheapplicationtodemonstrateyourabilitytoprovidethese services. ElectronicDataProcessingServices ComputerSoftware ElectronicDataProcessingEquipment Assessmentand/orAppraisalServices ElectronicDataProcessingConsulting Assessmentand/orAppraisalConsulting GeographicInformationSystems MicrographicsService MicrocomputersandPeripherals Other

Iftheapplicantisasubsidiary,parentcompanyorholdingcompany,listallotherbusinessrelationships
TradenameofFirm Active Inactive Divested Year Relationshipto ApplicantFirm When Where Organized

PrincipalBusiness

Iftheapplicantisasubsidiaryorparentorganizationandhaseverdonebusiness underothertradenames,specifyhere:
Year Changed Active Inactive Divested

FormerTradename

Year

MajorBranchOfficesoftheApplicantoritsRelatedFirms:

FirmName

Location



Services Provided by Applicant Describetheserviceswhichyourfirmcanperformandwhichthefirmwouldliketobeapprovedtoperform.



Qualifications Describetheexperienceandbackgroundwhichtheprincipalsandkeypersonnelinyourfirmpossesswhichshouldbe consideredintheevaluationthisapplication.

4

Financial Stability Attachhereabalancesheetandincomestatementforyourorganizationforthepasttwofiscalyears.

5

Narrative of Firm's History Sugestion:Describetheoperationalhistoryofthebusinessasitrelatestoexperiencegainedintheareaforwhichthis applicationismade.



Present Activities In Which Your Firm Is Involved NameandTypeofProject Location

NameandAddressofOwnerorOfficial

Estimated Contract Value

Percent Completed



TotalNumberofpresentprojects:

Totalestimatedcontractvalue:

7

Completed Work In Which Your Firm Was Involved During The Last 10 Years NameandType of Project Location Yearyour Work Completed

NameandAddress of OwnerorOfficial

Contract Value



Totalnumberofcompletedprojects:

Totalcontractvalue:



Personal History Statement of Principals and Associates Within Your Firm
A.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization) OtherThanPrincipal AsPrincipalinotherFirm DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization) (Furnish completed data but keep to essentials) D.Name(Last-first-middleinitial)

AsPrincipalinotherFirm

OtherThanPrincipal

MembershipinProfessionalOrganizations

MembershipinProfessionalOrganizations

B.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization) OtherThanPrincipal AsPrincipalinotherFirm

E.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization)

AsPrincipalinotherFirm

OtherThanPrincipal

MembershipinProfessionalOrganizations

MembershipinProfessionalOrganizations

C.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization) AsPrincipalinotherFirm OtherThanPrincipal

F.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization)

AsPrincipalinotherFirm

OtherThanPrincipal

MembershipinProfessionalOrganizations

MembershipinProfessionalOrganizations

9

(Continued) G.Name(Last-first-middleinitial) (Furnish completed data but keep to essentials) J.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization) OtherThanPrincipal AsPrincipalinotherFirm DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm

Personal History Statement of Principals and Associates Within Your Firm

AsPrincipalinotherFirm

OtherThanPrincipal

Education(College,degree,year,specialization)

MembershipinProfessionalOrganizations

MembershipinProfessionalOrganizations

H.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization) OtherThanPrincipal AsPrincipalinotherFirm

K.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization)

AsPrincipalinotherFirm

OtherThanPrincipal

MembershipinProfessionalOrganizations

MembershipinProfessionalOrganizations

I.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization) AsPrincipalinotherFirm OtherThanPrincipal

L.Name(Last-first-middleinitial) DateofBirth (mo-day-yr) YearsofExperience AsPrincipalinthisFirm Education(College,degree,year,specialization)

AsPrincipalinotherFirm

OtherThanPrincipal

MembershipinProfessionalOrganizations

MembershipinProfessionalOrganizations

0

Authorization

Theforegoinginformationissubmittedinsupportofthisapplicationforapproval.Thefactsanddatasubmittedarebelieved,tothebestofourknowledge,tobetrueandcorrect. ItisunderstoodthattheDepartmentreservestherighttocontactanyofthosepersonsorfirmsnamedtoverifyorinquire astotheperformanceoftheapplicant. TheDepartmentalsoreservestherighttorequestwhateversupportingdataitfeelsisnecessarytodeterminetheproper dispositionofthisapplicant. We hereby apply to have our firm's name placed upon the Department of Revenue's approved bidder's list. Signature of the Applicant:

Title Date