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 Telephone:
FAX:
800 FAX:
E-mail Address:
Web Address:
*Federal ID# (FEIN):

*EDI/Electronic Commerce capability:
If yes, please indicate the name of your value-added network for EDI:

*Does your company take Purchasing Credit Cards:
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:






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:

Commodities: Please complete the following checklist of commodities your firm wants to receive bid requests on.