Section 1 - Business Information |
Company Information |
| Vendor Type (*) |
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| Company Name (*) |
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| Federal Tax ID Number (*) |
(If you do not have an EIN, select the SSN option. If you select the SSN option, you will NOT be required to provide Social Security Number.)
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D&B DUNS Number (*)
(if unknown enter N/A) |
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| Physical Address (*) |
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| City (*) |
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| Country (*) |
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| State / Region (*) |
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| Zip / Postal Code (*) |
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| Remit To Address |
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| City |
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| Country |
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| State / Region |
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| Zip / Postal Code |
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| Company Phone Number (*) |
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| Company Fax Number |
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| Company Website (URL) |
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Contact's Information |
| Contact Name (*) |
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| Title (*) |
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| Phone Number (*) |
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Ext.
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| Fax Number (*) |
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| Pager Number |
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| Email Address (*) |
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Section 2 - Business Biography |
Company Data |
| Legal Structure (*) |
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| Is your company publicly traded? |
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| Corporate Stock Ticker ID |
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| Geographical Service Area |
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| Year of Inception (*) |
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| Number of Employees (*) |
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Section 3 - Products and/or Services |
Business Specialty |
Enter specific keywords describing your business specialty
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Section 4 - Diverse Supplier
If you are a Diverse Supplier, please complete Section 4, otherwise skip to Section 5. |
Principal Owner Information |
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| Are you SBA CCR listed? |
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Section 5 - Other Pertinent Information |
Annual Sales Volume(numbers only, no comma or decimal point. I.E., 3000000) |
| 2010 |
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| 2009 |
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| 2008 |
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References
List three current business customers (local or otherwise) which have been or are now your customers: |
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eBusiness |
| Can your system currently integrate with any of these eProcurement tools: Oracle/PeopleSoft, Ariba, SAP? |
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| By choosing to submit this form, you certify that the information you have provided above is true and accurate. |
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| Preparer's Name (*) |
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| Preparer's Phone (*) |
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Ext.
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| Preparer's Email (*) |
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