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Vendor/Supplier Classification
PLEASE FURNISH THE FOLLOWING INFORMATION ABOUT YOUR FIRM:
Company Legal Name:  
Phone Number  
Address 1  
Address 2  
City  
State  
Zip  
Contact Person  
Title  
Principal Product/Service  
Check if Current Vendor/Supplier  
Prepared By
(List person's Name)		  
Date Prepared
<May 2012>
SunMonTueWedThuFriSat
293012345
6789101112
13141516171819
20212223242526
272829303112
3456789


  
THIS IS TO CERTIFY THAT THIS BUSINESS QUALIFIES AS (CHECK ONLY THOSE THAT APPLY, USE
DROP DOWN SELECTION FOR MINORITY CLASSIFICATION)

Large Business Concern - A major corporation with more than 500 employees

    

Small Business Concern - A business concern independently-owned and operated which is not dominant in its field and which meets small business administration standards as to the number of its employees and/or dollar volume of its business (generally under 500 employees)

    

Minority Business Concern - A business at least 51% of which is owned (or in the case of publicly-owned businesses, at least 51% of the stock of which is owned) by one or more ethnic minority individuals or other individuals found to be disadvantaged as established by the Small Business Administration and whose management and daily operations are controlled by such individuals.

 Ethnic Minority

Gender Minority
  

Women-Owned Business Concern - A business that is at least 51% owned by a non-minority woman who controls the daily management.

    

Veteran Owned - A business at least 51% of which is owned (or in the case of publicly-owned businesses, at least 51% of the stock of which is owned) by one or more US military veterans.

    

None of the Above

    
       
CERTIFICATION STATUS
My company is certified by and authorized agency ( please email a copy of certificate)