Vendor Application

Thank you for your interest in becoming a vendor for Shell Point Retirement Community. At Shell Point, we strive for excellence in caring for, serving and satisfying our residents and employees. If you are interested in supporting our core values by providing the highest quality products or services to Shell Point, please fill out the vendor application below to begin the process. Thank you.

Contact Information

Your Name*

First Name

Last Name

President/CEO/General Manager Name

Email*

President/CEO/General Manager Phone

Phone*

President/CEO/General Manager Email

Fax

Licensing Information

State of Florida License Number

Lee County Business Tax Receipt Number

State/County Contractor License Number

Other Licensing

What percentage of present work is?

Government

Commercial

Non-Profit

Other

Insurance Information

Insurance Provider

Insurance Company Phone Number

Insurance Company Address

Address Line 1

Address Line 2

City

State

ZIP Code

Insurance Liability Cover Limits

Worker's Compensation Coverage

Reference #1

Reference Company #1 Name*

Reference Company #1 Phone Number

Reference Company #1 Contact Person

Reference Company #1 Email Address

Reference #2

Reference Company #2 Name*

Reference Company #2 Phone Number

Reference Company #2 Contact Person

Reference Company #2 Email Address

Reference #3

Reference Company #3 Name

Reference Company #3 Contact Person

Reference Company #3 Email Address

Reference Company #3 Phone Number

Certify

I certify that all the information above is true. If any of the information provided if found to be false, I understand that the application will be disqualified from consideration. *

Agree

Otherwise, I understand my application will not be reviewed.

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