Vendor Information Profile

Enter Information

Privacy Statement
*Required Field

Company Information

* Full Name of Firm or Company

* Contact Person

* Address

Address 2

* City

* State

* Zip

* Phone

( ) -

Fax

( ) -

* E-mail

* Confirm E-mail

Company Website Address

Business License

Sales Tax ID

Organization Information

*Type of Organization
(Check all that apply)

Small Business Enterprise (SBE) - Previous year's gross annual receipts did not exceed $2M for non-construction or $5M for construction.

Physically Challenged Business Enterprise (PBE) - At least 51 percent owned and controlled by one or more disabled individuals.

Women Owned Business Enterprise (WBE) - At least 51 percent owned and controlled by one or more non-minority women.

Minority Owned Business Enterprise (MBE) - At least 51 percent owned and controlled by one or more individuals of African American/Black, Hispanic American, Asian-Pacific American, Asian-Indian American, or Native American heritage.

None of the above.

Minority Information

* Minority Status

African American/Black

Hispanic American

Native American

Asian-Pacific American

Asian-Indian American

None of the above

* Has your firm been certified as Small, Minority, Women-Owned, or Disadvantaged Business Enterprise?

Yes
No

If yes, Specify the Certifying Agency

Date of Certification

(mm/dd/yyyy)

Expiration Date

(mm/dd/yyyy)