Supplier Diversity Development Registration Form

Last event your company attended:
 

Contact Information
* Contact Name:
  Contact Title:
  Contact Phone:
* Company Name:
* Contact E-mail:
  Company Website Address:
  Address1:
  Address 2:
  Town/City/Country:
  Postal Code:
  Country:

Company Owner/Officers
* Name:
  Title:
* Phone:
* E-mail:
  Address1:
  Address 2:
  Town/City/Country:
  State/Province
  Postal Code:
  Country:
   
Please check the appropriate box:
 
SBA Hub Zone
   
Company must be at least 51% owned, controlled and actively managed by a minority, woman or veteran. Check all that apply:
 
Black
Hispanic
Asian Pacific
Native American
 
Woman-Owned
Veteran-Owned  
Asian Indian
 
 
Please check which certifications you have:
NMSDC (or regional affiliate)
WBENC
SBA
NVBDC
CAMSC  
US Dept of Veteran Affairs
WEConnect International (or regional affiliate)

Information about your company
  Area of Service Capability: (Check all that apply)
 
Local
Regional
National
International
     
  Dunn & Bradstreet Number:
  Gross Sales Last Fiscal Year:
  Number of Employees:
  Year Business Established:
     
  Identify any Applicable Labor Organizations or Union:
 

Business
 
Manufacturer
Sales Representative
Distributor
Agent/Broker
Services
 
Other     
   
  Did your company receive any outstanding claims, pending litigation, prior bankruptcies pertaining to the company or any of its principles?
  Yes (Attach explanation)     No
 

If yes, please explain:

  List methods, equipment, systems, your company utilizes to assure superior product/service quality:
 
  Type of Ownership:
 
Corporation
Publicly Held
Privately Held
Parent Company
 
Partnership
Sale Proprietorship
Subsidiary
Division
  Is your company controlled by other companies?     Yes   No
         If yes, state name and division:  
  Briefly, list products and services offered and special capabilities:
 
  Key Customers:
       1       2        3

Certifications and Compliance
  Identify any quality certifications and regulatory organizations with whom you comply:
 

       ISO9000        ISO14001        TS16949

  Did your company earn any awards, honors, special citations?  If yes, explain: