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	Supplier Diversity

MWDVBE Registration and Profile Form

General Information

Company Name:

Address 1:

Address 2:

City:

State:

Zip:

Federal Tax ID #:

Dun & Bradstreet #:

Web Site:

Contact First Name:

Contact Last Name:

Contact Title:

Contact Phone:

Contact Fax:

Contact Email:

(E-mail)

Business Type

Business Classification (Check all that apply)

{If other, please define}

Business Ownership (Check all that apply)

{If other, please define}

Has your organization been certified by a third-party organization?

Yes No

If so, which organization? (Check all that apply)

National Minority Supplier Development Council (NMSDC) or its affiliate

Certification No.:			Exp. Date: MM/DD/YYYY

Women's Business Enterprise National Council (WBENC) or its affiliate

Certification No.:			Exp. Date: MM/DD/YYYY

Small Business Administration or its approved certification organization

Certification No.:			Exp. Date: MM/DD/YYYY

State Government

Certification No.:			Exp. Date: MM/DD/YYYY

Municipal Government

Certification No.:			Exp. Date: MM/DD/YYYY

Local Purchasing Councils

Certification No.:			Exp. Date: MM/DD/YYYY

Self Certification

Certification No.:			Exp. Date: MM/DD/YYYY

Other

Supplier Profile

Year Company Founded:

Annual Sales:

Number of Employees:

Number of Minority Employees:

Is Your Company EDI-ready?

Yes No

Is Your Company EFT-ready?

Yes No

Geographical Area Served:

Products/Services Provided:

Major Customers:

Customer Name:	Contact Name:	Phone Number:

Enter Security Code:

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