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Building Efficiency(BE) North America �0��o�� Regional Supplier Record Add/Change Form Forward to Supplier Addition Team �cneck one� ❑ BE Service/Systems/SP Fax#4145243776 or eMail: CG-SupalierAddTeamCcaici.com (Oracle) ❑ BE National Service Fax#4145243776 or eMail: CG-SuaalierAddTeamCcaici.com (Lawson) ❑ BE FMS/GWS Fax#: 866-907-9007 or eMail: FMS Supplier Suaaort(caici.com (Oracle) Note: All required information MUST be supplied on this form or it will be returned to the REGiUESTER. REQUESTER:Tracey DeVille Branch/District#:W99 FMS/GWS Account Name:Humana U.S. Form completed by: Phone: 1 �go-pppp Fax: 813-7�0005 Date: 1-18-2012 Add supplier to the following business system: ❑ Oracle ❑ Lawson ❑ Maximo(GWS/FMS only) Oracle only: Add supplier to the following database(s): ❑ United States ❑ Canada ❑ SPHQ Lawson only: MAPICS Supplier: ❑ Yes ❑ No SIEBEL/ASSIST: ❑ Yes ❑ No �Add new supplier ❑ Re-ACtivate supplier# Check all ❑ Additional Site on existing supplier# that apply ❑ Change information on existing supplier# ❑ Invalid site is (Zip&City) (Include new site below.) Supplier Name �REQUIRED�: Clty Of ZepllyT'tL1lls Purchasing/dispatch site address: (No PO Box) Pay site/remit to address: 5335 8th Street 5335 8th Street Zephyrhills, FL 33542 Ze�yrhills, FL 33542 Supplier Contact: First name: Bobbie Last name: S�,etland Phone� 813r7�0020 Fax: 813-7�0021 eMail: bswetlandC�i.zephyrhills.fl.us This supplier is: � Incorporated, or ❑ Not Incorporated � US Federal Tax ID (9 digits) ❑ Canadian GST ❑ US Social Security number and full legal name of person: Tax ID Number: N � Minority/Women Owned Business: ❑ Yes ❑X No Small Business �T Yes ❑ No �lunicipality � �� Supplier Type(defines risk) Pick one: ❑AgenUSales Consultant ❑ Business ConsultanUProfessional Fees 3 ❑ Chariry ❑ Customer ❑ Customs Broker/Freight Forwarder ❑ Direct ❑ Employee ❑ Freight � � ❑ Financial/Leasing/Insurance � Government Agency/Municipality ❑ Government Facing Business Consultant W � ❑ Indirect ❑ Inter-Company ❑ Landlord ❑ Sponsor ❑ Sub-contractor/Services ❑ Union/Court Ordered oC Q Payments ❑ Utilities L � Note: Refer to BOS process,'Global Supplier Add/Change Process#13-51.201.BEHQ',for supplier type definitions. Brief descri tion of item/service rovided: PaY�t for Places of Assgnbly Perndt@7400 Gall Blvd Humana office Check if the supplier addition is required per a check request. ❑ ep yr s, Payment terms for supplier: ❑ Net 60(1 and 22 ) Payment terms for subcontractors: ❑ Net 60(1 and 10 ) Note: Refer to BOS process,`Supplier Payment Terms Change Requests#13-21.208.BEHQ',for payment terms other than Net 60. Form#13-51.600.BEH� Page 1 of 4 Effective Date 15-June-2009 This document contains trade secrets and proprietary information of Johnson Controls,Inc. Disclosure of this publication is absolutely pmhibited without the ex ress written ermission of Johnson Controls,Inc. 0 2009 Johnson Controls,Inc. All ri ts reserved.