Vendor Modification Form

Purchasing Services
399 Challenger Road Cape Canaveral, FL 32920
Phone: (321) 783-7831/Fax: (321) 868-2184
Email: Click here

Vendor Modification

Instructions:

Please complete the digital form below or download the PDF version. A completed W-9 and COI (if applicable) MUST be submitted with your application.

Please review insurance requirements here.

If submitting a PDF version - please upload below.

By submitting this vendor application, you acknowledge that you have read and agree to the Canaveral Port Authority’s Terms and Conditions, which may be updated from time to time.

PROOF OF INSURANCE MUST ACCOMPANY ALL VENDOR APPLICATIONS AS REQUIRED UNDER THE GUIDELINES FOR INSURANCE COVERAGE REQUIREMENTS AND COVERAGE LIMITS.

**PLEASE FILL IN ALL INFORMATION ON FORM. MISSING INFORMATION MAY RESULT IN A DELAY IN PROCESSING APPLICATION**

Remit to Address (Mailing Address where you would like payment sent)

Address:

City:

State:

ZIP:

Office Phone:

Cell Phone:

Preferred Method of Communication

Office

Cell Phone

Contact Name:

Title:

Contact Email:

Physical Address

Physcial Address:

Physical City:

Physical State:

Physical ZIP:

Physical Office Phone:

Physical Cell Phone:

Physical Preferred Method of Communication

Office Phone

Cell Phone

Physical Contact Name:

Physical Title:

Physical Contact Email for Questions on Insurance:

Vendor Modification Form