Application is (Required) New  Updated Information  Reinstatement

ADDRESS INFORMATION:

Company Name (Required)

Contact Name (Required)

E-mail (Required)

Street Address (Required)

City, State, Zip (Required)

Country (Required)

Phone (Required)

Fax (Required)

REMITTANCE ADDRESS (if different from above):

Company Name

Street Address

City, State, Zip

Country

Commodities and/or Services (List products you wish to bid on) (Required)

Vendor Classification (Required) Corporation
Partnership
Limited Liability Corp. (LLC)
Subchapter S Corp.
Individual
Sole Proprietorship
Foreign National
Not-for-Profit Organization
Attorney/Legal Firm
Medical/Healthcare
Government Agency/Entity

Federal Tax ID No. (Business Only)

MINORITY BUSINESS CLASSIFICATIONS:

MINORITY BUSINESS ENTERPRISE (MBE) - A small business that is certified as being at least fifty-one percent (51%) controlled by one or more ethnic minority persons of either gender. (An ethnic minority person shall be described as African-American, Hispanic Americans, Native Americans, or Asian & Pacific Islander Americans).

WOMEN BUSINESS ENTERPRISE (WBE) - A small business that is certified as being at least fifty-one percent (51%) controlled by one or more women.

HANDICAPPED BUSINESS ENTERPRISE (HBE) - A small business that is certified as being at least fifty-one percent (51%) controlled by one or more handicapped persons of either gender.

Please check all that apply Minority Business Enterprise (MBE)
Women Business Enterprise (WBE)
Handicapped Business Enterprise (HBE)

Name of Person Completing Form (Required)

Title (Required)

Date (Required)