Vendor Ownership Information Form

2. Application Type*

   1. New

   1. Change/Update
3. Federal ID or Social Security #*
5. Business Name*
7. Business Address*
9. City*
10. State*
11. Zip Code*
13. Remit Address (if different from business address)
15. City
16. State
17. Zip Code
19. Status of Ownership (select at least one)*

    Information is collected for reporting purposes only and not vendor selection. Please check any or all of the following that apply to the ownership of your firm. 

    1. Prefer not to disclose
    2. Not Applicable

    1. Minority-Owned
    2. Woman-Owned

    1. Veteran-Owned
    2. Small Business
21. How are you certifying?*

    1. Certificates Attached

    1. Self-Certifying
22. Upload Certificate(s)
24. Primary Contact Person (Bids/Quotes/Purchase Orders)
25. Official Capacity
27. Phone Number
28. Fax Number
30. Email Address
32. Persons Authorized to Sign (Bids/Quotes/Contracts)
33. Official Capacity
35. Persons Authorized to Sign (Bids/Quotes/Contracts)
36. Official Capacity

38. By submitting this form you hereby certify that the information supplied is true and correct.

Leave This Blank:


40. Submit

* indicates a required field