Fill out all areas of the form before submitting. All items marked * are required before the form can be submitted.
*Company Name:
*Address
Street:
City: State: Zip:
*Telephone:
800/888 Telephone:
FAX:
800/888 FAX:
*Federal ID# (FEIN):
E-mail Address:
www-Internet Address:
*EDI/Electronic Commerce capability:
Yes
No
If yes, please indicate the name of your value-added network for EID:
*Does your company take Purchasing Credit Cards:
Yes
No
If yes, please indicate types:
*Name of Sales Representative:
*Title:
Telephone: FAX:
Bid Address:
(if other than above)
*Type of Organization:
*Business Classification/Code (as defined in Public Law 95-507.) Please check all that apply:
Small Business
Disadvantaged Business
Woman-Owned (WBE)
Minority Business (MBE)
None of the Above
A Small Business is a business that fits the specific size standard as contained in Code of Federal Regulations 13 CFR 121.

A Woman Business Enterprise (WBE) is a business concern that is (1) at least 51 percent owned by one or more women or–in the case of a publicly-owned business–at least 51 percent of the stock is owned by one or more women; and (2) whose daily business operations are managed and directed by one or more of the women owners.

A Disadvantaged Business as defined by Public Law 95-507, is 51% owned by socially and economically disadvantaged individuals.

A Minority Business Enterprise (MBE) is a business concern that is (1) at least 51 percent owned by one or more minority individuals or–in the case of a publicly-owned business–at least 51 percent of the stock is owned by one or more minority individuals; and (2) whose daily business operations are managed and directed by one or more of the minority owners.

Name of Person Completing Form:

Title:
Date:
We would appreciate receiving a copy of your catalog or other literature which describes your firm's products and/or services.
Commodities: Please complete the following checklist of commodities your firm wants to receive bid requests on.
Select multiple options from each list. On a PC, hold down the CTRL keyboard key while clicking once on your choices. On a Macintosh, hold down the OPTION keyboard key while clicking once on your choices.