PSC - Supplier Diversity Application

Company Name:	*
Company Address:	*

City:	*

State:	*	Zip:	*
Website Address:	*
Contact Name:	*	Job Title:	*
Phone:	*
Fax:
Email:	*

	Please describe the products and/or services you offer.
	*
	Are you currently providing this product/service?
	*
	Please list the geographic areas you can serve.
	*

Legal Company Name:*	Percentage Ownership:*

Legal Structure:*	Specify Other:

Year Established:*	Number of Employees:*

Dun & Bradstreet Number:*	Tax ID:*

	Standard Industrial Codes (SIC) or North American Industry Classification System (NAICS) Codes:
	*

% of Minority Ownership:*	Business Type:*

Please select the applicable category:* For further information and definitions, please reference the following links: National Minority Supplier Development Council. or Women's Business Enterprize National Council.

	Asian Indian American
	Hispanic
	Asian Pacific
	Native American
	Black American
	Non-Minority Woman

Are you a US Citizen?*

Yes
No

If you are a small business, do you have any of the following certifications? Please refer to the links (??) following each certifications for further information:

Incomplete

Small Disadvantaged Business*(??)	Yes No
HUBZone*(??)	Yes No
Service-disabled veteran owned small business*(??)	Yes No

Please provide your certification information.

Certifying Organization:	*
Certification #:	*
Expiration Date:	*


	Some required fields are incomplete. These have been highlighted in red.

SUPPLIER DIVERSITY APPLICATION

Are you a US Citizen?*

Small Disadvantaged Business*(??)

HUBZone*(??)

Service-disabled veteran owned small business*(??)

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