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Supplier Diversity Application Form
Name Supplier Diversity Application Form
Business Information
Consent for storing submitted data
*
Yes, I give permission to store and process my data
Business Name
*
Address
*
State/Province
*
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Island
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Country
*
United States
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Zip/Postal Code
*
Website
Leave as 'N/A' if you don't have a website.
Primary Industry
*
Accounting
Advertising
Arts and Entertainment
Communication Installation
Computer Cabling
Computer Hardware
Computer Software
Computer Software Development
Computer Supplies
Computer Systems
Construction Materials
Construction / Interior Decorators
Courier Services
Electrical Services
Electronic Equipment Repair
Field Services
Fleet Leasing
Fleet Services
Framing
Freight Services
General Contractor
Janitorial Services
Lawn Maintenance
Legal Services
Marketing
Miscellaneous
Non-Profit and Community Services
Office Furniture
Office Supplies
Other
Painting
Personal Growth and Enrichment
Plumbing
Printing / Commercial
Printing / Ticket Stock
Printing / Bet Slips
Professional Services
Public Relations
Real Estate
Retail
Retailer Training
Security
Snow Removal
Software Development
Staffing Services / Permanent
Staffing Services / Temporary
Technical Maintenance
Travel Services
Vending Machine
Select the most appropriate option.
Contact Information
Name
*
Job Title
*
Email
*
Phone
*
Fax
Other Information
Owner Title
*
Owner First Name
*
Owner Last Name
*
Is the owner a US Citizen?
Yes
No
Annual Revenue
Under $500,000
$500,000 - $1 Million
$1 Million - $2 Million
$2 Million - $5 Million
$5 Million - $10 Million
$10 Million - $12 Million
$12 Million - $15 Million
$15 Million - $20 Million
$20 Million+
Number of Full-Time Employees
Under 25
25 - 50
50 - 100
100 - 500
500+
Number of Part-Time Employees
Under 25
25 - 50
50 - 100
100 - 500
500+
Supplier Diversity Group Member
African American
Asian Indian
Asian/Pacific Islander
Disabled Business
Disabled Veteran Business
Hispanic
Native American
Veteran Owned
Woman Owned
Certification(s)
Veteran-Owned
DVBE
Sheltered Workshop
HUB Zone
Small Business Enterprise
Select all that apply.
Are you certified with NMSDC?
Yes
No
Are you certified with WBENC?
Yes
No
Are you a current SG vendor?
Yes
No
Are you able to hire sub-contractors if necessary?
Yes
No
Do you have a company brochure?
Yes
No
Do you have an organizational chart?
Yes
No
Business References
Company Capabilities
Comments
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