Preferred Vendor Program - Step 1

*Minority Category:

*Company Name:

Parent Company:

Physical Address

*Address Line 1:

Address Line 2:

*City:

*State:

*ZIP Code:

Physical address is home office

Mailing address is different from physical addresss

*Phone:

Fax:

Website:

*Email:

*Key Contact's Name:

*Key Contact's Title:

Employer's Federal Tax ID#:

SSN (For Indv Only):

Owners/Stakeholders

Please list each owner, proprietor, partner, officer, member, director and stockholder. The name listed should include Minority Group Members and Non-Minority Group Members.

*Name:

*Title:

*Gender:

*Years of Ownership:

*Ownership Role:

*Ownership Percentage:

*Voting Percentage:

*Minority Category:

+ Add Another Owner/Stakeholder

Key Individuals

Identify those individuals (owners, non-owners and key employees) who are responsible for the day-to-day operations and policy decision-making, including those with prime responsibilities for:

*Financial Decisions:

*Name:

*Title:

*Signatory on Major Documents:

*Name:

*Title:

*Accounts Receivable:

*Name:

*Title:

*Marketing/Sales:

*Name:

*Title:

*Estimating/Bids:

*Name:

*Title:

*Supervision of Field Operations:

*Name:

*Title: