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Company Name

Cocoa Beach Contact

Please provide the name or department you are currently working with. This will allow us to contact the department or person the business has been added to our Vendor List.

Remittance Address

Address2

Physical Address

Address2

Account Receivable Contact Information

Purchase Order Contact Information

Preferred Method of Payment

Fees Acknowledgement*

I hereby acknowledge and accept full responsibility for and and all transactions fees associated with electronic payments made to me by the City of Cocoa Beach.

This includes but is not limited to, fees related to credit card transactions and any other electronic payment method.

By signing below, I confirm that I am aware of and agree to bear the financial responsibility for all fees associated with e-payments, and I release the payer from any liability in this regard.

Occupation Licenses - if applicable

Required Documents

To be added to the City of Cocoa Beach Vendor List we require:

W-9 Form
Certificate of Insurance (if performing a service)

Certification*

Under penalty of perjury, I certify that:

The number shown on this form is my correct taxpayer identification number AND
I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup holdings as a result of failure to report all interest or dividends, OR
I am a U.S. person (including a U.S. Resident Alien).

Public Records Statement

Pursuant to Chapter 119 Florida Statutes, all information submitted to the City of Cocoa Beach is considered public record and open to inspection by the public.

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Under Florida Law, email addresses are public records