LCPA Vendor Application

For your business to be included on the Lee County Port Authority vendor/bidder list, please complete this form and commodity code selections.

TAX FILING STATUS

 
Check the box that applies to you and complete the appropriate fields below. 
*Application Type:
New Application
Address Change Only
Update to Existing Application
 
*Check One:
Individual/Sole Proprietor
Non-Profit Organization
Partnership
Corporation
Government
Foreign
 

VENDOR INFORMATION

 
 
Federal Tax ID #:

If using SSN please print application and fax or email to purchasingoffice@flylcpa.com
 
Tax Exempt Certificate #:
 
Business Name:
 
Doing Business as (DBA):
 
Parent Company Name:
 
Address:
 
City:
 
County:
 
State:
 
Zip Code:
 
Country:
 
Business Phone:
Include Area Code 
Fax Number:
Include Area Code 
Mobile Phone:
Include Area Code 
Website Address:
 
Contact Name:
 


REMITTANCE ADDRESS

 
(if different than above) 
Remittance Name:
 
Remittance Address:
 
City:
 
State:
 
Zip Code:
 


LICENSING INFORMATION

 

 
State Certified License #:
 
 
State Registration License #:
 
 
Lee County Competency License #:
 
 
 

WOMEN, MINORITY-OWNED AND OTHER SMALL BUSINESSES CERTIFICATIONS

 

 
 
Please check or list the type of certification(s) that your entity currently holds. 
DBE
ACDBE
MBE
WBE
SDV
SDB
SDE
8(a)
 
Other - Provide Type and Name of Certifying Agency(s):
 
 
 
CHECK ALL THAT APPLIES: 
BLACK AMERICAN, a person having origins in any of the Black racial groups of Africa Diaspora, regardless of cultural origin
 
HISPANIC AMERICAN, a person of Spanish or Portuguese culture with origins in Spain, Portugal, Mexico, South America, Central America, or the Caribbean, regardless of race
 
NATIVE AMERICAN, persons who are American Indians, Eskimos, Aleuts, or Native Hawaiians
 
ASIAN-PACIFIC AMERICANS, which includes persons whose origins are from Japan, China, Taiwan, Korea, Burma (Myanmar), Vietnam, Laos, Cambodia (Kampuchea), Thailand, Malaysia, Indonesia, the Philippines, Brunei, Samoa, Guam, the U.S. Trust Territories of the Pacific Islands (Republic of Palau), the Commonwealth of the Northern Marianas Islands, Macao, Fiji, Tonga, Kirbati, Juvalu, Nauru, Federated States of Micronesia, or Hong Kong.
 
SUBCONTINENT ASIAN AMERICAN, which includes persons whose origins are from India, Pakistan, Bangladesh, Bhutan, the Maldives Islands, Nepal or Sri Lanka
 
WOMEN-MINORITY OWNED
 
DISADVANTAGED BUSINESS ENTERPRISES
 
WOMEN, MINORITY-OWNED AND DISADVANTAGED BUSINESS ENTERPRISES: 
The Lee County Port Authority is dedicated to promoting the full participation of all small, women and minority-owned and disadvantaged business enterprises.  
To learn more about these programs you may contact the DBE Office at 239-590-4800 or visit LCPA’s website under the Bussiness Opportunities/Disadvantaged Business Enterprise (DBE) section. 
 

IMMIGRATION LAWS

 
 
Lee County Port Authority will not intentionally award County contracts to any contractor/vendor who knowingly employs unauthorized alien workers, constituting a violation of the employment provisions contained in 8 U.S.C. Section 1324a(e) Section 274A(e) of the Immigration and Nationality Acts (INA). 
Lee County Port Authority shall consider the employment by any Contractor of unauthorized aliens a violation of Section 274A(e) of the INA. Such violation by the recipient of the employment provisions contained in Section 274A(e) of the INA shall be grounds for unilateral cancellation of the contract by the Lee County Port Authority.
 
HOLD HARMLESS AND INDEMNITY CLAUSE: 
The Vendor shall indemnify, hold harmless, and defend Lee County, the Lee County Port Authority and their respective Board of Commissioners, their agents and employees and anyone directly or indirectly employed by either of them, from and against any and all liabilities, losses, claims, damages, demands, expenses, or actions either at law or in equity, including court costs and attorney’s fees, that may hereafter at anytime be made or brought by anyone on account of personal injury, property damage, loss of monies, or other loss, allegedly caused or incurred, in whole or in part as a result of any negligent, wrongful, or intentional act or omission, or based on any action of fraud or defalcation by the Vendor, or anyone performing any act required of the Vendor in connection with performance of the Contract awarded pursuant to this Vendor Application. By checking below, Vendor certifies that the person filing this application and listed below, has the authority to bind the Vendor and is authorized to agree to this clause on its behalf. These obligations shall survive acceptance of any goods, services, and/or performance and payment therefore by the Lee County Port Authority. When the work supplied is subject to FL Statute 725.06 the vendor will indemnify LCPA to the fullest extent allowable by law. 
I AGREE
I DISAGREE
 

COMMODITY CODES

 
 
Please carefully review the list of Contracting and/or Professional Services. Choose the services your company is able to provide to the Lee County Port Authority and enter them into the commodity codes text boxes. Include the commodity code number and name. (Indicate in the Products/Services Not Listed text box below, if you could not locate any services you provide.) 
 
Commodity/Services 1:
 
Commodity/Services 2:
 
Commodity/Services 3:
 
Commodity/Services 4:
 
Commodity/Services 5:
 
 
Products/Services Not Listed:
 
 

W-9 FORM REQUIREMENT

 
 

A W-9 Form is required prior to adding your company to our list. (Click here for a blank W-9 Form)


You can include your completed W-9 Form with your application by uploading it here:

 
(.pdf, .doc, .txt, .jpg, .gif only) 
 

INSURANCE REQUIREMENTS

 
 
VENDOR Agrees to maintain, on a primary and non-contributory basis and at its sole expense, at all times during the life of any resulting contract the following insurance coverages, including endorsements described herein. The requirements contained herein as well as the Port Authority’s review or acceptance of insurance maintained by the Vendor is not intended to and shall not in any manner limit or qualify the liabilities or obligations assumed by the Vendor under any resulting contract. Please refer to the insurance matrix for the specific limits of coverage required. 
COMMERCIAL GENERAL LIABILITY: Vendor agrees to maintain Commercial General Liability. Coverage shall not contain any endorsement(s) excluding or limiting Products/Completed Operations, Contractual Liability or Cross-Liability. Coverage should contain a waiver of subrogation in favor of the Port Authority. 
BUSINESS AUTOMOBILE LIABILITY: Vendor agrees to maintain Business Automobile Liability coverage that shall include liability for owned, non-owned & hired automobiles. In the event the Vendor does not own automobiles, Vendor agrees to maintain coverage for hired & non-owned auto liability, which may be satisfied by way of endorsement to the Commercial General Liability policy or a separate Business Auto Liability Policy. Coverage should contain a waiver of subrogation in favor of the Port Authority. 
WORKERS' COMPENSATION INSURANCE & EMPLOYER'S LIABILITY: Vendor agrees to maintain Workers' Compensation Insurance and Employer's Liability Coverage valid in the State of Florida. If not based in Florida this coverage should be highlighted in the description field of the Certificate of Insurance. Coverage should contain a waiver of subrogation in favor of the Port Authority. 
PROFESSIONAL LIABILITY COVERAGE: Vendor agrees to purchase Professional Liability Coverage in the event the Port Authority requests such coverage. 
ADDITIONAL INSURED: Vendor agrees to endorse the Lee County Port Authority as an Additional Insured on the Commercial General Liability with the following, or similar endorsements providing equal or broader Additional Insured coverage, the CG 2026 07 04 Additional Insured - Designated Person or Organization endorsement; or the CG 2010 10 01 Additional Insured - Owners, Lessees or Contractors or GC 2010 07 04 Owners, Lessees, or Contractors endorsement, including the additional endorsement of GC2037 1001 Additional Insured - Owners, Lessees or Contractors. 
Completed Operations shall be required to provide coverage for the Vendor’s work as defined in the policy and liability arising out of the products-completed operations hazard. The additional insured shall read “Lee County Port Authority.” 
The certificate holder address shall read: 
Lee County Port Authority
Attention: Risk Management
11000 Terminal Access Road
Suite 8671
Fort Myers, FL 33913-8213 
UMBRELLA OR EXCESS LIABILITY: Vendor may satisfy coverages and the minimum liability limits required above for Commercial General Liability or Business Auto Liability under an Umbrella or Excess Liability policy. The Certificate of Insurance must state the Umbrella or Excess Liability provides coverage on a “Follow Form” basis, and the Port Authority must be named an Additional Insured. Coverage should contain a waiver of subrogation for commercial general liability in favor of the Port Authority. 
Lee County Port Authority reserves the right, but shall not be obligated, to revise any insurance requirement, including but not limited to limits, coverages, and endorsements, or to reject any insurance policies which fail to meet the criteria stated herein. Additionally, the Port Authority reserves the right, but not the obligation, to review and reject any insurer providing coverage due of its poor financial condition or failure to operate legally. 
I AGREE
I DISAGREE
 
I hereby certify that the information supplied herein is correct: 
Name:
 
Title:
 
Email Address:
 
 
Please print this page for your records before clicking submit form.