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Supplier Diversity Registration Form

Please complete the form below to register as a diverse supplier.

* indicates required field

Company name *
DBA Name
Tax ID Number *
Address 1
Address 2
City
State
Zip Code
Phone * (Example: 000-000-0000)
Fax
Contact Name *
E-mail Address *
D&B DUNS Number
Cage Code
Primary NAICS Code
Secondary NAICS Code
Registered with Small Business Administration? *
Yes
No

Minority Owned Business (MBE)

(If yes, please select one ethnicity)

African American (AFA)
Asian-Pacific American (ASN)
Native Hawaiian Owned (NHO)
Hispanic American (HIS)
Alaska Native Owned (ANC)
Tribally-Owned (TBO)
Asian-Indian American (ASI)
Native American (NAM)
Other
Select all Diversity Classifications that apply
Women Owned Business (WBE)
Veteran (VET)
Disadvantaged/Disabled Person Owned Business (DBE)
City/State Certified HUB Vendor (HubCert)
Small Disadvantaged Business (SDB)
Service Disabled Veteran (SDV)
HubZone Small Business (HUBZ)
Lesbian-Gay-Bisexual-Transgender (LGBT)
Other
Type of Business*
please describe:
Legal Structure*
Service Area
International
National
Regional
Local
Please provide brief description of your Company's products/services (200 words or less)
Do you have an online catalog?
Yes
No
Can you sell your products/services online?
Yes
No
Are you Electronic Data Interchange (EDI) Capable?
Yes
No
Certified with Diversity Agency?
Yes
No
National Minority Supplier Development Council (NMSDC)

Certification Number

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Small Business Administration (SBA)

Certification Number

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Disadvantaged Business Enterprise (DBE)

Certification Number

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Women's Business Enterprise National Council (WBENC)

Certification Number

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Small Disadvantage Business (SDB)

Certification Number

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Historically Underutilized Business (HUB)

Certification Number

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Other (Please identify)

Organization


Certification Number

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)


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